Black Mental Health Canada Inc. Online Directory Request

Black Mental Health Canada Inc.

We are a non-profit organization set up to meet the needs of individuals within the black community who may require mental health services, and our goal is to help remove their current barriers to care. With this in mind, we are setting up an online directory network of practitioners who identify as black, African or from Caribbean heritage - to be service providers. There will be 2 types of clientele that would be reaching out to you. Persons who have insurance to pay your fees, and those that may require a sliding scale. If you agree to be on our directory, we ask that you complete the form below and your information will be added to our website.
Online Directory Consent Form

To give consent to have your information on our website please complete all questions.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Work Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Website
Population you work with?
What College are you associated with?

PsychotherapyPsychologySocial WorkOther
Do you offer a sliding scale? If so at what rate?*

YesNoOther
Clientele you are willing to work with?

InsuranceSliding ScaleBoth
How do you offer your service?

TelephoneFace to FaceVideoOther
Are you taking on new clients?*

YesNoOther
Signature*

Clear
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Online Directory Consent Form