Oasis Youth Center Mental Health Service Provider Interest Form

Thank you for your interest in collaborating with Oasis Youth Center to provide mental health services to queer youth. This Google Form is to provide us with a better understanding of you as a community service provider and the practices in which you conduct service delivery. If accepted, Oasis will use this information to create your service provider entry page within our Therapist Resource Guide. This form can also be used to update any changes in your service level or contact information.

Please answer the following questions to the best of your ability. If you have any questions about this form, please contact Oasis Youth Center at (253) 671-2838 or info@oasisyouthcenter.org.
First & Last Name: *
Pronouns: *
Current Title/Agency Affiliation *
Phone Number (for appointment and client contact) *
Email Address (for appointment and client contact) *
Additional methods of contact (for Oasis staff)
Physical Office Address *
Billing/Mailing Address (if different from above)
Accepted Payment Forms *
Do you currently accept mental health vouchers from Oasis? *
Please provide the name and credentials for your case consult provider or supervisor. *
Never submit passwords through Google Forms.
This form was created inside of Oasis Youth Center. Report Abuse