Welcome to emotilink

We designed emotilink not just for those seeking care, but for those delivering it, too.

Provider Signup
Please fill out the application form below to get started with emotilink.

First Name

Last Name

Phone Number

Birthdate

Email Address

Confirm Email Address

Password

Confirm Password

Gender

Please upload your profile photo: 1) Click "Choose File"

2) Select a .png, .jpg, .jpeg, .heif, .heic, .tiff or .bmp file

3) Click "Attach Profile Photo" to add the photo to your submission

Attach Profile Photo

About Yourself

Please upload a photo of your (1) Government Issued Photo ID and your (2) State Practice License: 1) Click "Choose File"

2) Select a .png, .jpg, .jpeg, .heif, .heic, .tiff or .bmp file

3) Click "Attach License Photo" to add the photo to your submission

Attach License Photo

Practice Address

Practice City

Practice State

Practice Postal Code

Qualifications

NPI Number

Languages Spoken

License Number

SSN

Tax ID

SSN or Federal Tax ID is required in order to receive payment for your sessions

We need you to answer a few questions about your professional fitness.
We will follow up with you by email if we have questions or need more information.

1. Have you ever been convicted of a crime, felony or misdemeanor? Yes No

2. Do you have any criminal charges currently pending against you? Yes No

3. Have you ever been subject to any disciplinary proceedings? Yes No

4. Has your license or right to practice ever been suspended or revoked? Yes No

5. Have you ever been sued for professional malpractice? Yes No

6. Do you have professional liability coverage? Yes No

7. Have you ever been licensed in a state other than where you currently practice? Yes No

Please read the following Terms and Conditions before submitting your application. You confirm your acknowledgement of these terms upon application submission.

Welcome to emotilink

We need you to answer a few questions about your professional fitness. We will follow up with you by email if we have questions or need more information.

We need you to answer a few questions about your professional fitness.
We will follow up with you by email if we have questions or need more information.