CJN Provider Registration Form

Register Your Mental Healthcare Services

The CountJoy Network's primary work is connecting Black people to Black therapists nationwide. We also work to connect other POC groups & LGBTQ persons to their respective culturally relevant therapeutic options. If you would like to be listed as a CJN provider, please complete the following registration form to join the movement. Please note: By submitting this form, you are giving the CountJoy Network & JoFoKe LLC permission to publish the information that you have provided in our free CJN directory.
Mental Healthcare Provider *

PrefixFirst NameLast Name
Name of Practice*
Your Racial and/or Ethnic Identity*
Business Phone Number*

Area CodePhone Number
E-mail*
example@countjoy.com
Website *
Do you offer online sessions, in-person, or both?*
Business Address (for in-person treatment)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Specialty(ies), please specify. *
What ages do you serve?*
What insurance do you accept? If none, please indicate n/a.*
Is there any additional information you'd like us to share?
Should be Empty:

Register Your Mental Healthcare Services