Provider Application Form

* Required Fields

Name and Last Name*

Identity Number*

Email Address*

Phone Number*

Physical Address*

Street Address Address Line 2 City* Province* Postal Code* Country *

UPLOAD YOUR ID (pdf, png, jpg)

Accepted file types: png, jpg, pdf, Max. file size: 64 MB.

UPLOAD YOUR MOST RECENT PHOTO (pdf, png, jpg)

Accepted file types: png, jpg, pdf, Max. file size: 64 MB.

UPLOAD YOUR CV (pdf, png, jpg)

Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.

UPLOAD YOUR HPCSA/SACSSP/ASCHP REGISTRATION DOCUMENT (pdf, png, jpg)

Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.

UPLOAD YOUR PRACTICE NUMBER REGISTRATION DOCUMENT (pdf, png, jpg)

Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.

HPCSA/SACSSP/ASCHP Registration Number*

Do you practice under a different name?

Practice registration number*

Private/Company VAT Number

How Would you like to be billed?

Name of your prefessional medical malpractice insurance

Membership Number

Amount Of Cover

Provide Details of Your Education

Diploma / Degree	Field	Institution	Year Completed	Actions

There are no Entries.

Provide Details of Your Experience

Company	Industry	Title	Summary	From	To	Actions

There are no Entries.

What do you specialize in?*

What are your current counseling Fees?

How much time can you devote to working through the Santum platform?*

Are you willing to conduct live video counseling sessions?*

Do you have adequate power supply to ensure uninterrupted sessions during load shedding?*

How many years have you been practicing counseling?*

How Many Counseling Hours Do You Have?*

Are you currently required to have supervision in order to provide counseling services?*

How many times do you check your email?*

Cover letter*

Please provide your registration information in all countries your are registered in, the registration number(s), and the expiration date(s).*

Do you have experience in providing counseling online? If so, please tell us about it.

Why are you interested in providing services online?

Please provide contact information of at least one registered therapist who can be your reference.

Do you have a history of any arrests, charges, convictions, or legal proceedings? If so, please provide details.

Have you ever been investigated or reviewed by the registering board? If so, please provide details.

Have you ever been subject to disciplinary actions by the registering board? If so, please provide details.

Which languages are you able to provide counselling in?

Please provide some details about your counseling style and approach

Do you understand that you will not be a Santum employee but an independent provider who provides services through the platform?

How did you hear about Santum?

Name

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