Onboarding form | TAG The Academic Gym

First name

Last name

Email

Phone

Address

Social Security Number

Please provide your SSN for a background check and tax reporting purposes. This information is securely stored and used solely for a background check and IRS Form 1099-NEC compliance.

What are the best ways, days, and times to contact you?

Certification

State where you are certified

NPI #

Are you registered with the CAQH database? If so, please enter your CAQH ID below. If not, you will receive an email with instructions on how to do so.

Yes

No

CAQH stands for Council for Affordable Quality Healthcare. It maintains a national database of provider information used for credentialing and enrollment.
A CAQH ID (or “CAQH number”) is automatically generated when a provider creates a profile in CAQH

CAQH ID number

Malpractice Insurance? If yes, please upload or email proof.

Yes

No

Compact Eligibility

Teletherapy Compact

OT Compact

None

Not sure

Preferred Service Modalities

Client Demographics Served

Other (explanation)

What is your primary purpose for seeking TAG VITAAL-K Therapy Certification?

How would you rate your current knowledge about movement-based literacy and the science of reading? This helps us personalize your training experience.

Beginner

Fairly well acquainted but would still like to start at the beginning

Expert

Preferred Onboarding Format

asynchronous videos, pdf's, etc

Live Zoom workshops

Hybrid

I attest that all the above information is correct and up to date.

I attest that I have read and signed the Independent Contractor's Agreement.*

I consent to a background check.

File upload

Proof of Insurance, Certification, NPI#, other docs

Please upload any supporting documentation. You may also email this information to info@theacademicgym.com

Clinician Onboarding