PVS Provider Intake Form

Please review the Required Documents Resource Guide for the intended service type before completing this form. Missing or incomplete information/documentation will result in a processing/approval delay. Submission review can take up to five business days. If you need to submit credentials for multiple schools, please complete one form for each school. Thank you.

Therapist/Provider Submission Type*

Please Select the correct Submission Type. This will help us better serve you.

Ticket Referral Number

Must provide the ticket referral number associated with this request. Enter "N/A" if the request is for following service types: Administrative; Captioner; ASL Interpreters.

Email and Name of Person Submitting Form*

If you are a vendor and are submitting this form on behalf of a therapist, please include your name and e-mail address here. All other information on this form will be the therapist's information.

Vendor Company or Individual Name*

Please include the company with which this therapist is associated.

Therapist Information

For the fields below, please enter the therapist's name and email, NOT your name and email if you are a liaison or account manager submitting on behalf of another person.

Therapist/Provider First Name*

If you are a liaison or account manager submitting on behalf of a therapist, please list their first name here.

Therapist/Provider Last Name*

If you a liaison or account manager submitting on behalf of a therapist, please list their last name here.

Therapist/Provider Email*

This is the therapist's e-mail address, and it is required to grant a Connexus Account

Service Type*

Select the actual service type the therapist will perform. This may or may not match the license type submitted in some instances.

Therapist availability per week (hours)*

Please enter the number of hours per week that the therapist is currently available to provide services to students.

Therapist's Current Availability*

Social Security Number (SSN)

SSN is required for state reporting purposes and will only be accessible to the Compliance team for the purpose for state reporting.

School Name*

Please indicate the school for which services will be provided based on credentials uploaded below. For Admin roles, do not list "All schools." In the "Have questions?" box below, please list schools where you have an active referral only.

Background check(s)

Please attach the required clearance documents. This could include items such as: FBI, State, Child Check, Sex Offender. Hold (Ctrl) when selecting multiple files for attachment. Files must be attached at one time and not individually.

Credential(s) Upload

Please add the required credential document(s). This could include: DOE license or Board License. Hold (Ctrl) when selecting multiple files for attachment. Files must be attached at one time and not individually.

Miscellaneous

Please use this field to attach other documents not included in the above categories if needed. Hold (Ctrl) when selecting multiple files for attachment. Files must be attached at one time and not individually.

Ticket name*

Please name your submission ticket as outlined below. This will help us expedite your request and better serve you.

Naming Convention:
School Name_Therapist Name_Service Type

Example:
ACA_Jen Teacher_Occupational Therapy

Have questions? How can we help you?

We welcome your questions, comments or concerns.