Psychiatry Match
Connecting Nurse Practitioners & PAs with Collaborating Psychiatrists
NP / PA Intake Form Form NP-PA-01 · Confidential Version 2026
Tell us about yourself and your practice so we can match you with the right collaborating psychiatrist. This form takes about 5 minutes and covers your credentials, practice setting, licensure, and what you're looking for in a collaboration.
01 Personal & Credentials Basic Information
02 Your Practice & Why You're Here Helps Us Find the Right Fit
Why are you seeking a collaborating psychiatrist now? *
Where will you be seeing patients? *
Practice setting *
Will you be prescribing controlled substances? *
Patient population you will primarily serve
Approximate weekly patient volume (once fully practicing)
03 Ketamine & TMS Services Advanced Treatments
Do you currently offer or plan to offer ketamine therapy in your practice?
Do you currently offer or plan to offer TMS (Transcranial Magnetic Stimulation) therapy?
Are there any other specialized or advanced treatment modalities you offer or plan to offer?
Collaborating physicians at MD-Match are experienced with advanced treatment modalities. Disclosing your services helps us match you with a physician who has relevant clinical familiarity, which supports better collaboration and appropriate oversight.
04 Licensure, Collaboration & DEA Collaboration-Required States Only
Only states where NPs and PAs are legally required to have a collaborating physician are shown. States with full independent practice authority are excluded as no collaboration agreement is needed there.
Licensed In *
States where you hold an active NP or PA license
0 selected
Need Collaboration In *
States where you require a collaborative agreement to practice or prescribe
0 selected
Active DEA Registration
States where you currently hold an active DEA number (or plan to obtain one)
0 selected
05 Legal & Board Standing Required Disclosure
Do you have any current, pending, or past disciplinary actions with any state Nursing Board or Medical Board? *
Has your NP or PA license ever been suspended, revoked, or placed on probation in any state? *
Has your DEA registration ever been suspended, revoked, or voluntarily surrendered? *
Are you currently involved in any malpractice litigation? *
Disclosure of a past issue does not automatically disqualify you. All responses are reviewed confidentially by our team and evaluated in context. Omitting material information may result in removal from the platform.
06 One Last Thing
Fields marked * are required. All information is kept strictly confidential and is never shared publicly or sold. You will hear from our team within 3–5 business days.
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Application Submitted
Thank you — we'll review your application and be in touch within 3–5 business days.
Questions? Email pwase001@gmail.com