Full legal name *

Preferred professional name *

Email *

Phone

Credentials *

Professional title *

Short professional bio *

Pronouns

Languages spoken

Years of clinical experience

LicenseType *

License Number *

Licensing board name *

License State *

License Expiry Date *

Attestation that license is in good standing *

Yes

Compact or reciprocity eligibility

Yes

No

Supervisory credential

Yes

No

Primary Specialties *

Additional Specialties

Age groups served *

Clinician Type *

Core Therapeutic Approaches

Additional Approaches

Service Type *

Telehealth Platform Used *

States where telehealth is offered *

Office address

Current accepting new clients *

Yes

No

Waitlist availability

Yes

No

Time ranges *

Typical session frequency

Accepted payment methods: *

Insurance plans accepted *

Sliding Scale Available *

Yes

No

Superbills Provided

Yes

No

Agreement to Platform Terms *

I agree

HIPAA Compliance Acknowledgment *

I acknowledge

Scope of Practice Acknowledgment *

I acknowledge

Non-Discrimination Agreement *

I agree

Malpractice Insurance Carrier

Policy Number

Public Profile Visibility

On

Off

Preferred Contact Method

Platform Messaging

Email

Referral Only

Bio Tagline

Featured Specialties (top 3)

Interest in workshops or community events

Yes

Interest in content contributions

blogs

panels

webinars

1. BASIC IDENTIFYING INFORMATION

2. LICENSING & CREDENTIAL VERIFICATION (REQUIRED)

3. SPECIALTIES & CLINICAL FOCUS

4. POPULATIONS SERVED

5. THERAPEUTIC APPROACHES & ORIENTATION

6. CULTURAL & VALUES ALIGNMENT (VERY IMPORTANT FOR THIS PLATFORM)

7. SERVICE DELIVERY & LOGISTICS

8. AVAILABILITY & SCHEDULING

9. PAYMENT & INSURANCE INFORMATION

10. ETHICS, CONSENT & LEGAL ATTESTATIONS

11. PLATFORM & DIRECTORY SETTINGS

12. OPTIONAL ENHANCEMENTS (FOR FUTURE GROWTH)

Connecting black girls and women with trusted services and opportunities nationwide. Guided by our values of respect, inclusion, and excellence in every interaction.