Clinician Profile (New & Update)
Please complete this form to add a new clinician profile or update an existing profile in the PBH directory. For immediate booking schedule changes, please use the separate Immediate Booking Availability form.
Section 1: Form Purpose
What is this submission for?
*
New profile to directory
Update current profile
Profile photo
Upload Photo
Drag and drop files here
Choose a file
Optional — JPG or PNG, max 5MB
Cancel
of
Section 2: Identity & Credentials
First name
*
Last name
*
Email
*
example@example.com
Credentials / suffix
*
License type
*
Please Select
LMFT
LCSW
LPCC
PsyD
PhD
MD
PMHNP
AMFT (associate)
APCC (associate)
ASW (associate)
Other
License number
*
NPI number
*
Section 3: Bio & Clinical Focus
Professional bio
*
Would you like PBH to edit and rewrite your professional bio?
Yes. Rewrite and send it to me for review.
No. Please do not rewrite.
Specialties
*
Anxiety & stress
Depression
Trauma & PTSD
Relationship issues
Family conflict
Grief & loss
Life transitions
ADHD
Substance use
Eating disorders
LGBTQ+ affirming
Child & adolescent
Couples therapy
Bipolar disorder
OCD
Personality disorders
Other
Therapy approaches
*
CBT
DBT
EMDR
ACT
Psychodynamic
Motivational interviewing
Mindfulness-based
Solution-focused
Narrative therapy
Somatic
Other
Section 4: Clients Served
Age groups accepted
*
Children (5–12)
Adolescents (13–17)
Young adults (18–25)
Adults (26–64)
Older adults (65+)
Couples
Families
Groups
Languages spoken
*
English
Spanish
Mandarin
Cantonese
Tagalog
Vietnamese
Armenian
Farsi
Other
Section 5: Insurance & Fees
Insurance accepted
*
Aetna
Anthem Blue Cross
Blue Shield
Cigna / Evernorth
Gold Coast Health Plan
Health Net
Kaiser Permanente
LA Care
Medi-Cal
Medicare
Optum / United Healthcare
Self-pay
Sliding scale
Other
Self-pay session fee
Sliding scale range
Session type
*
Telehealth only
In-person only
Both
City / service area
Section 6: Education
Degree 1
*
Institution 1
*
Degree 2
Institution 2
Additional education / certifications
Section 7: Confirmation
Confirmation
*
I confirm the information submitted above is accurate.
Submit
Should be Empty: