Asian Pacific Islander South Asian American (APISAA) Therapist Directory
Mental Health Provider Information Sheet
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Welcome to the first information sheet for the early development of an Asian Pacific Islander South Asian American (APISAA) 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. Please be patient as we are always learning more about how this project will evolve and better fit the needs of providers and clients alike. Thank you so much for your interest in being included in this project as your work and representation matter greatly.
Clinician Name: *
Website URL:
Professional Email: *
Appointment Telephone Number: *
(xxx) xxx-xxxx
State: *
City: *
Zip Code: *
Full Name of Licensing Body (i.e., Texas State Board of Examiners of Psychologists): *
State Licensure Name and # (i.e., LMFT 1234, TX4567): *
Self-identified ethnic identity (i.e., Chinese, Korean, Japanese, Malaysian, Mixed Race - half Caucasian and Chinese): *
Area of Specialization (i.e., child, adult, LGBTQ, depression, anxiety, trauma, maternal mental health, etc): *
Languages, if any, which you use to offer services (aside from English): *
Do you accept insurance? If so, please identify. *
Do you offer sliding scale or reduced fee sessions? *
Do you offer Telehealth/Teletherapy sessions? *
Is there any other additional information which would be helpful for the administrators or clients to know about you?
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 administrators of this directory reserve 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? You will be notified if this is the case. *
Do you acknowledge that your practice is not endorsed in any way by the administrators of this directory and all professional conduct and liability falls within the clinician's ethical and legal obligations of their respective licensing body? *
If you have any suggestions for additional information that should be reflected or collected on this information sheet, please feel free to let us know.
Thank you again for taking the time to complete this information sheet. We sincerely appreciate your interest in this directory and for providing more mental health access to this community.
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