If you are an out of state behavioral health provider and licensed in good standing as a

• Psychologist
  
• Marital and family therapist
  
• Marital and family therapy associate
  
• Clinical social worker
  
• Master social worker
  
• Alcohol and drug counselor
  
• Professional counselor
  
• Behavior analyst
  
• Advance practice registered nurses who are certified by the American Nurses Association as a Psychiatric-Mental Health Nurse Practitioners
  
• Physician assistants with a Certificate of Added Qualifications in Psychiatry from the National Commission on Certification of Physician Assistants (hereinafter out of state telehealth providers)
  
• Physician certified by the American Board of Psychiatry and Neurology
  

Then you are eligible to provide mental health and behavioral health care and services via telehealth in the State of Connecticut under the Department of Public Health’s Commissioner’s order, upon completion of this enrollment form. Under the Commissioner’s order, you must apply for licensure, certification or registration with the Connecticut Department of Public Health in your field, within 30 days of completing this enrollment or secure a compact license from your home state within 90 days of completing this enrollment. If you do not comply with these deadlines, your authority to practice telehealth in Connecticut will be terminated.