Request edit access
Disability Counseling Provider Directory
Thank you for your interest in being listed on our site. We are only listing providers who are competent in working with clients with a disability or who specialize in a particular disability/chronic illness. If you fit that criteria, please complete this form and we will review it to add to our list of providers. This is currently a free service we are providing and therefore will be a very basic profile to keep our costs down. If this changes at any time and Disability Counseling Institute needs to start charging for this service, we will provide appropriate notice. You may opt out at any time.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Middle Name
Last Name *
Credentials (i.e. LMHC, LMFT)
States you're licensed in (choose at least one) *
Required
Do you accept insurance? *
Do you do Telehealth *
Website
Rate per Hour
Phone Number
Short Description of you and/or your services (three to five sentences) *
Additional description of you and/or your services (optional, three to five sentences)
Photo
Please email sarah@disabilitycounseling.org with a photo. The photo should be about 300 pixels (px) in height and about 400 pixels wide and in jpg/jpeg format.
Acknowledgement *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Disability Counseling Institute. Report Abuse
Google Forms