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BIPOC Mental Health Professionals Registration
Hi there! Thank you so much for your interest in joining our BIPOC Mental Health Professionals Registry. Please read our mission statement before registering by clicking on the blue text below. If you have any questions or feedback, please email thelavendercollective.ca@gmail.com.
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Your information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Website 1
https://www.example.com
Website 2
https://www.example.com
Social media platforms
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Your professional information
Do you practice a profession regulated by an order/requiring a permit? If so, please select which one(s) below. If not, please skip to the next question.
Psychologist
Social worker
Psychiatrist
Couple and family therapist
Sexologist
Psychoeducator
Psychotherapist / psychotherapy permit
Guidance/Career counsellor
Dietician
Please enter your Order of Psychologists permit number
*
Please enter your Order of Social Workers permit number
*
Please enter your Doctors' College permit number
*
Please enter your Order of Couple and Family Therapists permit number
*
Please enter your Order of Sexologists permit number
*
Please enter your Order of Psychoeducators permit number
*
Please enter your Psychotherapy permit number
*
Please enter your Order of Guidance Counsellors of Quebec permit number
*
Please enter your Order of Dieticians of Quebec permit number
*
Do you practice a profession not currently regulated by an order? If so, please select which one(s) below.
Indigenous healer
Indigenous elder
Art therapist
Drama therapist
Counsellor
Movement therapist
Music therapist
Life coach
Spiritual worker/healer
Somatic Experiencing Practitioner
Other
Which association(s) are you part of?
*
I am not part of an association
Association des medecins psychiatriques du Québec
Association des art-thérapeutes du Québec
Association des psychothérapeutes du Québec
Association des éducateurs et éducatrices spécialisés du Québec
Association médicale de Québec
North-American Drama-Therapy Association
Quebec Association for Music Therapy
Dance Movement Therapy Association of Canada
Association of Cooperative Counselling Therapists of Canada (ACCT)
Canadian Psychiatric Association
Canadian Counselling and Psychotherapy Association (CCPA)
Association des sexologues du Québec
Association of Naturotherapists of Quebec
Quebec Counselling Association
International Coaching Federation
Ordre des Conseillers et Conseillères d'Orientation du Québec
Your personal information
How would you describe your ethnicity/race?
*
Can you also describe your ethnicity/race in French?
What language(s) do you fluently speak?
*
French
English
Arabic
Spanish
Cantonese
Mandarin
Haitian Créole
Cree
Japanese
Tagalog
Tamil
Punjabi
Inuktitut
Atikamekw
Innu
American Sign Language
Quebec Sign Language
What gender do you identify with?
*
Male
Female
Non-binary
Prefer not to say
Do you identify as LGBTQ2S+?
*
Yes
No
Prefer not to say
Do you identify as trans?
*
Yes
No
Prefer not to say
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Your services
Who do you provide services to?
*
Children (ages 0-5)
Children (ages 6-13)
Youth (ages 14-24)
Adult (ages 25-64)
Older adult (65 and up)
Family
Couple
Your treatment approaches
*
Accelerated Experiential Dynamic Psychotherapy (AEDP)
Acceptance and Commitment Therapy (ACT)
Adlerian
Applied Behavioural Analysis
Attachment-based
Biofeedback
Brainspotting
Coaching
Cognitive Behavioural (CBT)
Cognitive Processing (CPT)
Culturally Sensitive
Dialectical (DBT)
Eye Movement Desensitization and Reprocessing
Eclectic
Emotionally Focused
Existential
Experiential Therapy
Expressive Arts
Family Systems
Feminist
Forensic Psychology
Gestalt
Gottman Method
Humanistic
Hypnotherapy
Imago
Integrative
Internal Family Systems (IFS)
Jungian
Mindfulness-Based (MBCT)
Motivational Interviewing
Narrative
Neuro-Linguistic
Neurofeedback
Parent-Child Interaction Therapy (PCIT)
Person-Centered
Play Therapy
Positive Psychology
Prolonged Exposure Therapy
Psychoanalytic
Psychobiological Approach Couple Therapy (PACT)
Psychodynamic
Rational Emotive Behaviour Therapy (REBT)
Reality Therapy
Relational
Solution Focused Brief (SFBT)
Somatic
Spiritual Counselling
Strength-Based
Structural Family Therapy
Transpersonal
Trauma Focused
Please check off all needs/experiences you work with. You will be able to share any additional specializations in your bio at the end of this form.
*
Addiction
ADHD
Adoption
Alzheimer's
Anxiety
Behavioural Issues
Chronic Illness and/or Pain
Developmental Disorders
Divorce
Domestic Violence
Eating Disorders
Emotional Issues and Disorders
Family Conflict
Grief
Intellectual Disability
Learning Disabilities
Life and/or Work Coaching
Medication Management
Parenting
Peer Relationships
Personality Disorders
Pregnancy, Prenatal, Postpartum
Racial Identity
Relationship Issues
School Issues
Self Esteem
Self-Harming
Sex Therapy
Sexual Violence
Sexuality and Gender Issues
Sleep or Insomnia
Spirituality
Sports Performance
Stress
Substance Use/Abuse
Suicidal Ideation
Testing and Evaluation
Transgender Issues
Trauma and PTSD
Traumatic Brain Injury
Are your services located at a fixed address?
*
Yes
No
Where are your services located?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you offer your services remotely (text/phone/video)?
*
Yes
No
Please check off the accessible facilities your space offers
Elevators if not located on the ground floor
Ramps / no stairs at every door
Enough room for wheelchairs to move freely
Gender-neutral washrooms
Scent-free space
Non-fluorescent lighting
Automatic doors
Fully accessible washrooms
Accessible parking
Full COVID-19 sanitation procedure
Please enter the range of your hourly rate?
*
What methods of payment do you accept?
*
Cash
Cheque
Credit
E-transfer
PayPal
Interac/Debit
Check off all mandates / coverage you accept:
*
IVAC
CAVAC
CALACS
CNESST
SAAQ
PFSI
None
In compliance with your professional ethical regulations and standards, do you offer a sliding scale payment option?
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Yes
No
In compliance with your professional ethical regulations and standards, do you accept barter/trades as a payment option?
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Yes
No
Can your services be covered by insurance?
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Yes
No
Do you offer attestation letters for trans individuals?
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Yes
No
Please share a personal bio with us. Feel free to talk about your specializations. This will be shared on the website to help users understand who you are and what services you offer so they can make the best choice for their needs. Please respect the maximum 250 words limit.
*
0/250
Please share your personal bio in French as well. This translation can be as short or as long as you wish. If you cannot provide a translation, users will have the option to use an external software to automatically generate a translation. Please respect the maximum 250 words limit.
0/250
Please upload an image of yourself. The image will be used on our website, for your personal profile. If you do not feel comfortable sharing an image of yourself, we will use a profile icon.
Do you know other mental health practitioners of colour who would be interested in being part of this directory? Please list their names and contact information below!
Thank you!
Thank you so much for taking the time to fill in this form. Once you are done completing the form, please press the "Submit" button below!
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