Group and provider Data Application Form

You don’t join us, we join you! We appreciate and thank you for your interest in allowing us to join you to serve all Aetna Better Health of OhioRISE members. Please complete this data application accurately and correctly. Failure to provide all required data elements results in delay in processing your application. If there are any questions, please email us at

Note: WM-Withdrawal Management

Telehealth Services


Select ASAM level of care certification(s) by checking the applicable boxes below.

ASAM Level 1
ASAM Level 2 WM
ASAM Level 2.1
ASAM Level 2.5
ASAM Level 3.1
ASAM Level 3.2 WM
ASAM Level 3.3
ASAM Level 3.5
ASAM Level 3.7 WM
ASAM Level 3.7
ASAM Level 4

Please select additional areas of education/training.

Specialized Services Provider Level
Assertive Community Therapy (ACT)
Adoption Assistance
Alternative Education
Applied Behavioral Analysis (ABA) -- Autism Services
Art Therapy
Attachment, Self-Regulation, and Competence (ARC)
Before and After School Programs
Behavioral Health Respite
Behavioral Health Urgent Care
Bridges program to assist in independent and transitional living services for young adults.
Childcare Training and Workshops
Child-Parent Psychotherapy (CPP)
Children's Day Treatment 8-14 Years of Age
Cognitive Behavioral Therapy (CBT)
Criminal Justice Services
Crisis Mobile Team
Crisis Services
Crisis Stabilization Unit
Cue-Centered Therapy (CCT)
Culturally Relevant Services for Native American Youth
Day Treatment Program
Deaf and Hard of Hearing Services
Dialectical Behavior Therapy (DBT)
Eating Disorders
Expressive Writing
Eye Movement Desensitization and Reprocessing (EMDR)
Family Support Services
First Episode Psychosis (FEP) Early Psychosis (EEP)
Foster Care Assistance
Foster Care Treatment (recruits) family and treatment level foster care providers who are trained)
Functional Family Therapy (FFT)
Gambling Disorder Support
Group Home
Group therapy for adolescents with complex trauma (TF-CBT (Trauma Focused Cognitive Behavioral Therapy))
Help Me Grow
High Fidelity Wraparound
Home Based Services
Housing Services
Independent Living (aging out of foster care)
Integrated Dual Disorder Treatment (IDDT)
Intensive Outpatient Program (IOP)
Jail Based Treatment Program
Juvenile Sex Offender Program males 10-17
Kinship and Peer Support (Youth Peer Support and Family Peer Support)
LGBTQ+ Resources
Life Skills Center
Medically Monitored Detox
Medication Assisted Treatment (MAT)
Medication Management
Mom and Me Recovery
Multisystemic Therapy (MST)
OCD (Obsessive Compulsive Disorder)
Office-Based Opioid Treatment (OBOT)
Out of Home Respite
Onsite Childcare
Parenting Education
Partial Day Treatment
Partial Hospitalization Program (PHP)
Prenatal Behavioral Health Services
Problem Sexual Behaviors/Coercive Sexual Behaviors
PTSD (Post Traumatic Stress Disorder)
Recovering Housing
Registered Play Therapy
Residential 18 and up for services
Residential Treatment
School Based Programs
Screening Brief Intervention Referral to Treatment (SBIRT) ASAM
Skills Training in Affective and Interpersonal Regulation/Narrative Story Telling (STAIR/NT)
Social Drop in Centers
Special Education and treatment services for children and adolescents
Specialized Day Treatment Center 18 months to 8 years old (IOP)
Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)
Substance Use Disorder Treatment
Supported Employment
Therapeutic Foster Care
Transitional Aged Youth
Trauma Affect Regulation: Guide for Education and Therapy (TARGET)
Trauma Informed Care (TIC)
Trauma Systems Therapy (TST)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Treatment for Foster Care Families
Vocational Services
Women's MICA House
Women's Residential Treatment
Wraparound-informed Approach


By submitting this document you're certifying that to the best of your knowledge, the information provided is accurate.