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