Help for LA Fires: If you're a therapist in California and would like to offer sliding scale, pro-bono, or insurance-based therapy to support those who lost their homes, evacuated during the LA fires, or are otherwise affected, we’d be thrilled to have you join this list!
*You can remove yourself from the list at any time if your schedule fills up. If someone inquires and you’re not the right fit, feel free to direct them back to the list for additional options.
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Email *
Name and License (i.e. Maria Evans, LMFT) *
Specialty (What populations do you see? And if you have a trauma or grief or somatic specialization, work with first responders, etc. that's important to know.) *
Sliding scale, pro bono, or both? Insurance? (if insurance, list which one) *
Office location: Share your cross-streets or neighborhood and tell us if online is available (or write "Online only" if you're online only) *
Contact: Include just one way of contacting you. Website is good. If you don't have a website, email or phone works well, too. *
Please share your license number. By doing so, you are confirming that you are authorized to practice psychotherapy in California. *
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