Climate-Aware Therapist Referral List Form
Not a therapist but someone looking for climate-aware therapy to help you or a loved one with climate-related distress? Click here: https://tinyurl.com/climateawareclientele

The Climate Psychiatry Alliance (www.climatepsychiatry.org) and the Climate Psychology Alliance North America (www.climatepsychology.us) are recruiting allied mental health professionals who can deliver high-quality, climate-aware psychotherapy for inclusion in an online, public referral list to connect with interested clients and meet the proliferating needs of climate-stressed and climate-distressed individuals and communities.

Read our Climate-Aware Therapist Pledge here (also on the second page of this form if you are filling it out): https://tinyurl.com/climateawaretherapist

Please contact Alex Trope, MD with any issues or questions about this form: hello@alextrope.com
Email address *
Name *
Your answer
Professional Degree with Which You Practice Psychotherapy *
Current Job Title (if different from above degree)
Your answer
Affiliate Organizations
Your answer
State in which you are licensed to practice (please write out State name completely, no abbreviations) *
Your answer
Do you hereby affirm that you are currently licensed and in good standing with your professional licensing organization? *
Zip Code *
Your answer
Clinical Areas of Expertise (non-climate) *
Your answer
Climate-Related Areas of Interest (particular issues within climate and mental health that you have professional, personal or academic experience with) *
Required
Mental Health Services You Provide (Individual, Couples, Group Psychotherapy, Child & Adolescent, Medication Prescribing, Teletherapy, Mind-Body Practices, etc.) *
Your answer
Are you a member of Climate Psychiatry Alliance or Climate Psychology Alliance North America? (paying members of either will not have to pay administrative costs of maintaining referral list) *
Required
Contact Information for Interested Clients (Website, LinkedIn, Intake Phone Number, etc.) *
Your answer
Please include your personal contact information (phone number), in case we have additional questions. *Neither this number, nor the email provide at the beginning of this form, will be included in the database, and they will not be shared with any third parties.* *
Your answer
Please provide your professional license numbers for all states in which you can practice psychotherapy. *
Your answer
Are you also interested in being on a public Climate and Mental Health Speakers List? (must have experience giving pertinent presentations or speaking publicly on topic of climate change). *
If you answered yes to the preceding question, please provide the title, approximate date, and venue/event/publisher of any important presentations, interviews or written pieces related to climate and mental health that you have done. If there is any online footprint of this, please include the corresponding URL. Please press the "Enter/Return" key to make a new line for each item.
Your answer
You will now be directed to read and attest the Climate-Aware Therapist Pledge, which is necessary for any consideration or final inclusion on the Referral List.
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