Free Black Therapy Therapist Sign Up
Hi,

Free Black Therapy is connecting with Black or African American or other mental health therapists who may be interested in working with us!

This is part-time work for currently practicing Psychotherapists who meet the following criteria:

• Black or African American or other mental health counselors/providers (Licensed, Associate level, and Pre-licensure welcome to apply)

• Can take on 1-2 or more clients within the next month and provide them with up to 5 sessions of 1-hour each (45 or 50 minute therapeutic session)

• Position is fully remote, the provider must have their own HIPAA compliant video/audio conference capabilities

• The sessions are prioritized for Black or African American individuals, 18+, with low income and lacking health insurance. All are welcome to sign up.
_____________________________________________________________________________
• If you are interested in working with us, this is HOW IT WORKS:
1. We will confirm with you all the details you provide in this form (billing, availability, number of clients etc.) before matching you with a client(s).
2. Then the client(s) will be notified to contact you, and you must respond within 2 business days.
3. Provider will submit a monthly invoice to Free Black Therapy here https://forms.gle/mLQxnFHqiQspfBZ89

• Free Black Therapy will pay the session fee that you indicate in this form (must be considered "reasonable compensation" according to the IRS) for 5 sessions, through your preference of PayPal, CashApp, or EFT.

• By signing up, you are committing to meeting these expectations

Please sign up if you are interested. Or if you know therapists who may be interested, please send them our way. All questions, knowledge, and advice are welcomed! We believe feedback is a gift, so the more the merrier!

Eternally grateful,
Free Black Therapy
Sign in to Google to save your progress. Learn more
Email *
Full Name *
License Type *
Required
License Number *
License State - please indicate all states you are able to provide teletherapy services in. *
Can you provide HIPAA Compliant Teletherapy? *
If applicable, are you under proper supervision and your supervisor will assume all liability for HIPAA Compliant Teletherapy? *
How much does your session fee cost? *
How many clients can you take on in the next month? (5 sessions per client) *
Areas of Specialty? *
Required
How do you identify yourself? *
Required
Gender
Clear selection
Want to tell us anything else?
If a client asked you to sign up, please indicate here in order to be matched with them.
Do you agree to the terms and conditions, privacy policy, and Provider Agreement? You can find them at the links below. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google.