• Therapy Fund Foundation Provider Application 2026

    Complete this application for initial review or annual renewal, and note that submission does not guarantee approval or referrals.

  • Provider Identity

  • Format: (000) 000-0000.
  • Public Directory Contact Preference*
  • Racial / Ethnic Identity*
  • States Licensed In*

  • Eligibility and Qualifications

  • Do you hold a master's degree?*
  • Do you have at least two years of experience working with Black/African American communities?*
  • Have you completed formal anti-racism training?*
  • Do you engage in ongoing personal anti-racism work?*

  • License and Supervision

  • Expiration Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Practice Status*
  • Expected Full-Licensure Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
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  • Insurance and Compliance

  • Image field 84
  • Includes sexual abuse/molestation coverage*
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  • Practice Details

  • Service Format*
  • Accepting New Clients*
  • Ages Served*
  • Works with Children*
  • Do You Work With Couples ?*
  • Specialties ( Check all that apply )*
  • Insurance Accepted*

  • Rates

  • Directory and Documents

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  • Agreements and Certification

  • Provider Agreement

     

    Terms & Privacy Policy

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: