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 email@example.com.
Social media platforms
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.
Couple and family therapist
Psychotherapist / psychotherapy permit
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.
Somatic Experiencing Practitioner
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?
American Sign Language
Quebec Sign Language
What gender do you identify with?
Prefer not to say
Do you identify as LGBTQ2S+?
Prefer not to say
Do you identify as trans?
Prefer not to say
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)
Your treatment approaches
Accelerated Experiential Dynamic Psychotherapy (AEDP)
Acceptance and Commitment Therapy (ACT)
Applied Behavioural Analysis
Cognitive Behavioural (CBT)
Cognitive Processing (CPT)
Eye Movement Desensitization and Reprocessing
Internal Family Systems (IFS)
Parent-Child Interaction Therapy (PCIT)
Prolonged Exposure Therapy
Psychobiological Approach Couple Therapy (PACT)
Rational Emotive Behaviour Therapy (REBT)
Solution Focused Brief (SFBT)
Structural Family Therapy
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.
Chronic Illness and/or Pain
Emotional Issues and Disorders
Life and/or Work Coaching
Pregnancy, Prenatal, Postpartum
Sexuality and Gender Issues
Sleep or Insomnia
Testing and Evaluation
Trauma and PTSD
Traumatic Brain Injury
Are your services located at a fixed address?
Where are your services located?
Street Address Line 2
State / Province
Postal / Zip Code
Do you offer your services remotely (text/phone/video)?
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
Fully accessible washrooms
Full COVID-19 sanitation procedure
Please enter the range of your hourly rate?
What methods of payment do you accept?
Check off all mandates / coverage you accept:
In compliance with your professional ethical regulations and standards, do you offer a sliding scale payment option?
In compliance with your professional ethical regulations and standards, do you accept barter/trades as a payment option?
Can your services be covered by insurance?
Do you offer attestation letters for trans individuals?
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.
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.
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 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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