Welcome to Sacred Healing lights International (SacredHLI)

This brief Stage 1 PMHNP Readiness Check (2 Minutes) helps us confirm baseline fit for our remote, 1099 telehealth model. Please complete this form accurately. If you meet Stage 1 criteria, you’ll be contacted with next steps.

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Name *

First

Last

Email *

Email

Confirm Email

Licensure: I hold an active, unrestricted PMHNP license in at least one of the following states: California (CA); Texas (TX); Arizona (AZ) or Georgia (GA) and can practice independently within my licensed scope. *

Yes
NO

Which state license(s) do you currently hold? *

California (CA)
Texas (TX)
Georgia (GA)
Arizona (AZ)
Colorado (CO)
Nevada (NV)

Select all that apply.

Employment Strcuture: I currently maintain one or more W-2 roles or other stable income sources and am seeking a supplemental 1099 telehealth engagement, not guaranteed full-time income. *

Yes
No

Availability (Ramp Phase) *

I can realistically and reliably support 5-15 billable hours per week over the next 3-6 months.
I cannot support this range.

Compensation Structure: I understand and accept that this is a billable-only 1099 role, with: No guaranteed hours; No standby pay; No payment for non-billable time. *

Yes
No

Name telehealth Strcuture:

Malpractice Insurance (1099 Requirement) *

I currently carry an individual professional malpractice insurance appropriate for PMHNP practice.
I do NOT currently carry it, but am willing to obtain coverage prior to activation.
I am not willing to obtain individual malpractice coverage.

State-Specific Prescribing Requirements (Awareness): I understand that additional state-specific prescribing requirements may apply. If I choose to prescribe, and where required by state law, such requirements must be independently secured by me. *

Yes
No

Work Model Confirmation: I am comfortable working in a fully remote, asynchronous, low -meeting environment, with written policies, no micromanagement, and high professional autonomy. *

Yes
No

Sacred Healing Lights International, Inc | Confidential Provider Screening

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