SF Project Access Provider Registration Form
SF Project Access is a volunteer run, public service web application resource whose goal is to provide a one-stop solution for mentally distressed, treatment-seeking individuals in the San Francisco Bay Area to receive comprehensive screening for the most common mental disorders and to find treatment providers who would be 1) available to them (i.e. affordable, accepting new patients) and 2) particularly knowledgeable about the conditions from which they may be suffering. We want to allow treatment-seeking individuals to filter provider results based on geographic location, gender, familiarity with cultural issues, including LGBTQ issues, and types of therapies provided (e.g. cognitive behavioral therapy, acceptance and commitment therapy, psychodynamic psychotherapy, medications, transcranial magnetic stimulation, etc.)

To that end, we would love to include all San Francisco Bay Area mental health providers who are licensed and able to see patients in our database. Please review and complete the questions below.

Email address *
First Name *
Your answer
Last Name *
Your answer
Year of Birth
Your answer
Ethnic Background
Languages Offered *
Required
License Type *
Terminal Degree *
Office Phone *
Your answer
Office Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Handicap Accessible? *
ADA Services Offered *
Required
Website Address
Your answer
Year You Were First Licensed to Practice *
Your answer
Diagnoses/Problems Treated *
Required
Treatment modalities employed *
Required
Cultural Competencies
Religious and Spiritual Competencies
Are you accepting new patients? *
Do you participate on any insurance panels? *
If so, which ones?
Do you provide telehealth services? *
What is your out-of-pocket hourly rate? *
Do you offer a sliding scale in your practice?
Brief Biography
Your answer
Would you like to provide a photo of yourself for your Bio? (provide public hyperlink to image in space below)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service