Provider List Application
Mental Health and Medical Practitioners interested in joining our resource list can fill out this form.
I am a...
What is the contact information for your practice? Phone number and address.
Your answer
What are your credentials?
Your answer
What populations do you generally serve?
Your answer
Do you have any areas of specialty?
Your answer
What insurances are you in-network with?
Your answer
Do you offer a sliding scale?
Your answer
What languages do you speak?
Your answer
Have you worked with LGBTQ individuals before?
Have you worked with youth before?
Tell us a little about yourself and why you should be added to our resource list.
Your answer
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