The Asian Mental Health Collective (AMHC) Therapist Directory New Provider Application Form
Welcome to the new provider form for the AMHC Therapist Directory. The information gathered here is intended to help build a resource for potential clients who might be seeking mental health providers in their area. If your application is accepted, you will be notified of further steps within 2-3 weeks at the email provided. Please be patient as we are always learning more about how this project can evolve and better fit the needs of providers and clients alike. Thank you so much for your interest in being included on our directory as your work and representation matter greatly.
Sign in to Google to save your progress. Learn more
Clinician Name, Credentials (Professional Title) *
Ex. John Dorris, LPC
License Number. If an associate, license of supervisor required. *
Professional Email (must not be a shared email address) *
Website URL
Phone Number
Country *
US State(s) of Licensure
Canadian Province(s) of Licensure
Self-Identified Ethnic Identity *
Required
Office/Home State/Province *
Office/Home City *
Office/Home Zipcode *
Do you acknowledge that the information included in this form is subject to verification of publicly accessible information through state licensing boards in order to protect public safety. * *
Do you acknowledge that the Asian Mental Health Collective reserves the right to pause your participation in this directory if the information provided is not accurate, correct, or licensure status is unable to be verified? *
Do you acknowledge that your practice is not endorsed in any way by the Asian Mental Health Collective and all professional conduct and liability falls within the clinician's ethical and legal obligations of their respective licensing body? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Asian Mental Health Collective. Report Abuse