Provider Registration Form
Name
First Name
Last Name
Email
example@example.com
Website
In what state are you licensed to practice?
Select the following Certifications that apply
Certified Mental Health Advocate
Certified Mental Health Coach
Social Worker
Licensed Social Worker (LSW)
Licensed Clinical Social Worker (LCSW)
Licensed Graduate Professional Counselor (LGPC)
Licensed Clinical Professional Counselor (LCPC)
Other
If "Other" selected, please specify certification/license type:
Accepting New Patients
Please Select
Yes
No
In-Person Sessions
Please Select
Yes
No
Virtual Sessions
Please Select
Yes
No
Self Pay Accepted
Please Select
Yes
No
Accepts Insurance
Please Select
Yes
No
Sliding Scale Available
Please Select
Yes
No
Type of Insurance Accepted
Please list all types of insurance accepted.
Would you like to upload a picture of yourself?
Please Select
Yes
No
Image Upload
Browse Files
Drag and drop files here
Choose a file
Please upload an image/picture with the following file type: JPEG, JPG, PNG or TIF.
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PROOF OF CREDENTIALS
Browse Files
Drag and drop files here
Choose a file
Please upload proof of your credentials. This is for verification to be listed on the website. This is not for public use and will not be displayed on the website. Please include a watermark on all images to prevent identity theft.
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