Holistic Melanin Provider Application

Warning!* This field is required.Failure to provide appropriate information will cause your application to be reject and put on a "no acceptance list" for 6 months.

Uploading a non front facing photo. (Landscapes, text, flyers)

Uploading a document that is not associated with your practice as credentials. (Blank pdf's, etc)

All the above

First & Last Legal Name* This field is required.

First Name

Last Name

Your Gender* This field is required.

Your Pronouns* This field is required.

She/Her

He/Him

They/Them

DOB* This field is required.

Personal Phone Number* This field is required.This phone number will be used to update you on your profile.

Personal Email Address* This field is required.This email address will be used to update you on your profile.

example@example.com

Profile Photo* This field is required.Profile photo must be a clear front facing photo, non face photos will be automatically rejected and put on the "No Acceptance List" for 6 months.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Years In Practice* This field is required.

Phone Number for Clients* This field is required.Displayed as in on your profile.

Please enter a valid phone number.

Email Address for Clients* This field is required.Displayed as in on your profile.

example@example.com

Official Title* This field is required.To be displayed on the main directory page of your profile, ex: Licensed Marriage and Family Therapist, Certified Nutrition Coach, Yoga Instructor.

40 Character Limit

Website / Social Page* This field is required.Must include https:// or http://

This will be dsplayed as is on you individual profile.

City and State of Your Practice* This field is required.

City

State

Country

Addt'l. City and State You're Licensed InLicensed in more than 2 states, add additional states in the Information Box below.

City

State

Country

Credentials* This field is required.You must upload a BBS Certificate, a Certificate of Completion, or any credentials earned in your field. If you do not, you must have been in business for a minimum of 1 year and have a minimum of 10 reviews.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Inacurate credentails = automatic rejection

Fee Range* This field is required.The fee range should start at your lowest fee of all modalities and services to your highest. *Ex: Ind Rate = $100 , Family Rate = $250, Range: $100 - $250

Tag Line/ Quote* This field is required.To be displayed on the main directory page of your profile. 100 Character Max

Bio* This field is required.Introduce yourself.

To be displayed on your practitioner profile. 200 words Min | 400 Max.

0/400

Service Type* This field is required.Select up to 2.

Chiropractor

Coach

Counselor

Doula

Healer

Massage : Somatic : Stretch Therapist

Mind-Body Fitness Instructor

Nurse Practitioner

Nutritionist

Physician

Physical / Occupational Therapist

Psychiatric NP

Psychologist

Registered Dietitians (RD/RDN)

Spiritual Counselor

Therapist

Yoga Instructor

Specialty* This field is required.Select all that apply.

Academic/ Educational

Addiction

Adult Trauma

Anger Management

Anxiety

Art

Career

Childhood Trauma

Child Development

Depression

Domestic Violence

Eating Disorder

EMDR

Empowerment

Energy

Family Conflict

Finance

Grief

Gender Identity

Hypnonsis

LGBTQ+

Meditation

Mindfulness

Music

Organization

Parenting

Personal Development

Productivity

PTSD

Physical Therapy

Racial Issues/ Identity

Relationships

Religious Identity

Self-Esteem

Sex

Stress

Transformation

Yoga

Other

Modality* This field is required.Select all that apply.

Individual

Couples

Family

Group

Corporate

Session Type* This field is required.Select all that apply.

In Person

Virtual - Everywhere

Virtual - Within My State

Accepted Pay* This field is required.Select all that apply.

Private Pay

Insurance

Accepted Insurance* This field is required.Select all that apply.

Aetna

Alameda Alliance

Beacon Health Options

Blue Cross and Blue Shield Association

Cigna

Kaiser Permanente

United Health Care

UBH

Medicare

Medicaid

Optum

TriWest

I do not accept insurance.

Other

Accepted Pay By* This field is required.Select all your private pay options.

Cash

Check

Credit Card

Venmo

Cash App

Zelle

Paypal

Other

Ages I Work With* This field is required.

0 - 9yrs

10 - 15yrs

16 - 20yrs

21 - 39yrs

40 - 60yrs

18+

21+

61yrs+

Sexualities I Work With* This field is required.

Heterosexual

Homosexual

Lesbian

Gay

Bisexual

Questioning

Asexual

Pansexual

Other

Genders I Work With* This field is required.

Women

Men

Nonbinary

Trans Women

Trans Men

All

Other

Language(s) Spoken* This field is required.

English

Swahili

Patois

Arabic

Creole

French

Spanish

Amharic

Yoruba

Somali

Guyanese

Igbo

Other

Additional Information

If you selected other as an option above, please explain. If you are licensed in more than 2 state please add them here.

Terms & Condition | Privacy Policy | Platform Policy | Scope of Practice

PLEASE READ THE FOLLOWING AGREEMENTS BELOW.

Terms & Conditions
Privacy Policy
Platform Policy
Scope of Practice

Confirmation of Policy reading.* This field is required.Confirm you have read the following Terms & Conditions Privacy Policy Platform Policy Scope of Practice

I confirm that the information provided is accurate and complete, and I agree to the Holistic Melanin Terms & Conditions, Privacy Policy, Platform Policies and Scope of Practice Agreement.

Signature* This field is required.By entering my full legal name below, I affirm that I am authorized to enter into this agreement and that my electronic signature is intentional, legally binding, and enforceable in accordance with applicable electronic signature laws.

Holistic Melanin Provider Application