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PROVIDER SIGN-UP FORM

First Name*
Last Name*
Email Address*
Phone Number*
License Type*
License Number
Zip code of Practice*
Gender
Other Gender
Age
Ethnicity
Other Ethnicity
Spoken Languages
What type(s) of services do you provide?*
- Individual Therapy
- Couples Therapy
- Family Therapy
- Group Therapy
- Play Therapy
- Art Therapy
- EMDR
- Brainspotting
- Psychological Testing
- Neurofeedback
- Other
Other Services
Focus: What issues do you enjoy working with? (Please select up to 5)*
- ADHD
- Anxiety
- Autism
- Bipolar
- Career/Academic Stress
- Children
- Chronic Health Issues
- Dependency
- Depression
- Domestic Violence
- Eating Disorders
- Faith-Based/Christian
- Financial Stress
- Grief/Loss
- Infertility
- Insomnia
- LGBTQ+
- Life Transition
- Men's Issues
- OCD
- Parenting
- Perfectionism
- Perinatal/Postpartum
- Personality Disorders
- Racial Trauma
- Racial/Cultural Identity
- Relationship Issues
- Self-Harm
- Self-Esteem
- Sex-Intimacy Issues
- Substance Abuse
- Teens
- Trauma/PTSD
- Women's Issues
- Other
Other issues you enjoy working with
How would you describe your IDEAL CLIENT?
Billing Options*
- Out of Pocket
- Sliding Scale
- Superbill
- Insurance: In Network
- Insurance: Out of Network Direct Billing
Insurance Company*
What is your rate per session?*
Which of these best describes your therapy style?*
- Short Term - With more of a solution-focused approach, short term therapy is ideal for those who are coming in with a specific problem they’d like to address and gain clarity on. Typically, short term therapies are present focused and do not dive deep into your past.
- Structured - Structured therapies are goal and progress oriented. In order to stay on track, therapists may provide worksheets and homework.
- Exploring the past - Getting to the root of the issue and finding deeper self-awareness can help with long-term change
- Non-directive - Going with the flow and seeing where it leads
- Behavioral (CBT, DBT) - Focuses on changing potentially unhealthy or self-destructive behaviors
- Trauma Focused - Recognizing the connection between trauma experiences and your emotional and behavioral responses, trauma focused therapy seeks to help you heal from traumas
- Other
How would you describe your therapy style?
Which days and times are you available to schedule clients?*
Session Types Offered*
- In-person
- Online
- Other
Other Session Types Offered
What else should we know about you to help make the best match?
Please upload your professional profile photo
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