Black Therapist Available for Black Clients
Sign in to Google to save your progress. Learn more
Email *
Clear selection
First and Last Name *
License type *
How do you Identify? *
If you are White or a Non Black Person of Color, have you done personal Anti-racist work and feel culturally competent to work with black people without racially retraumatizing them?
Do you offer Teletherapy /Virtual or In Person Sessions? *
If seeing clients in office only, where is your office location (city/state/ area) *
What state are you Licensed in? *
How much is your session fee? *
How many clients can you take on in the next two weeks (providing at least 4-6 sessions) ? *
What are your areas of specialty? *
Other areas of Speciality
Best Contact info for clients to reach you. Website, phone number, and email. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy