2025 Provider Roster Annual Update Form

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Update Period: Open through September 30th, 2025

NC CTP requires all clinician-trainees, clinician graduates, and non-clinician ABC and RPC providers to complete this update form each year, even if they do not choose to appear on the NC CTP Provider Roster. Clinician-graduates of CPP, CPT, PCIT, PSB-CBT™-P, PSB-CBT™-S, PSB-CBT™-A, SPARCS, SPARCS-ST, and/or TF-CBT are additionally required to affirm each year that they have met model-specific NC CTP Roster Requirements.

The Provider Roster Annual Update form typically takes 10-15 minutes to finish. Please allow 2-3 weeks for any changes to your name, licensure, and/or practice information to appear on the Provider Roster, as we receive a high volume of responses during the annual update period.

This form is due by September 30th, 2025. If we do not receive a response from you by the deadline, your information will be removed from the Provider Roster until you complete the update. If you have any questions about this policy, or if you need assistance with reappearing on the Provider Roster, please contact NC CTP. Thank you for completing the 2025 Provider Roster Annual Update! We sincerely appreciate your help ensuring that the Provider Roster contains only current and accurate information.

Note: If you are having trouble meeting rostering requirements for your model(s), we are here to help! Contact NC CTP if you are interested in receiving guidance or support for meeting requirements, or if you have questions about a specific rostering requirement.

NC CTP 2025 Provider Roster Annual Update Form
Which email address(es) do you wish to use for NC CTP correspondence?
How would you like your name to appear on the NC CTP Provider Roster and/or NC CTP graduate lists?
Did you use another name while enrolled in an NC CTP Learning Collaborative?
Are you interested in having your name and contact information listed on the NC CTP Provider Roster?
Please specify the language(s) in which you are fluent and able to provide mental health treatment (check all that apply):
Please indicate your clinical licensure (check all that apply):
Is your clinical license active and in good standing?
Since you last updated your NC CTP Provider Roster status, has your clinical licensing board imposed any restrictions that may limit the scope of your clinical practice?
Since you last updated your NC CTP Provider Roster status, have you been the subject of an investigation by your licensing board?
Since you last updated your NC CTP Provider Roster status, have you had a criminal conviction?
Note: The NC CTP leadership team reviews all concerns that arise through the Provider Roster Annual Update process, including responses to this questionnaire. A member of the team may reach out to you to clarify a response. A criminal conviction, and/or a clinical licensure board investigation and/or finding, may result in temporary–or permanent–removal of an individual from the NC CTP Provider Roster. A member of the NC CTP leadership team will contact you if circumstances warrant temporary or permanent removal of your listing(s) from the roster.