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1. BASIC IDENTIFYING INFORMATION

Full legal name *

Preferred professional name *

Email *

Phone

Credentials *

Professional title *

Professional Headshot *

Headshot

PNG, PDF, JPEG or JPG professional, clear, neutral background

Short professional bio *

Pronouns

Languages spoken

Years of clinical experience

Membership Tier *

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2. LICENSING & CREDENTIAL VERIFICATION (REQUIRED)

LicenseType *

License Number *

Licensing board name *

License State *

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License Expiry Date *

Attestation that license is in good standing *

Yes

Compact or reciprocity eligibility

Yes

No

Supervisory credential

Yes

No

Upload copy of active license *

PNG, PDF, JPEG, JPG, DOCX or DOC

3. SPECIALTIES & CLINICAL FOCUS

Primary Specialties *

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Additional Specialties

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4. POPULATIONS SERVED

Age groups served *

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Clinician Type *

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Additional Populations

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5. THERAPEUTIC APPROACHES & ORIENTATION

Core Therapeutic Approaches

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Additional Approaches

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

Cultural Responsiveness Statement *

Experience with Black Girls/Women *

Yes

No

Describe Relevant Experience *

Commitment to Culturally Informed Care

I agree

Areas of lived experience that inform practice (voluntary)

Community involvement or advocacy work

7. SERVICE DELIVERY & LOGISTICS

Service Type *

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Telehealth Platform Used *

States where telehealth is offered *

Office address

Accessibility accommodations

8. AVAILABILITY & SCHEDULING

Days of availability *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Current accepting new clients *

Yes

No

Waitlist availability

Yes

No

Time ranges *

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Typical session frequency

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Evening or weekend availability

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9. PAYMENT & INSURANCE INFORMATION

Accepted payment methods: *

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Insurance plans accepted *

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Sliding Scale Available *

Yes

No

Superbills Provided

Yes

No

Session Fee Range

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10. ETHICS, CONSENT & LEGAL ATTESTATIONS

Agreement to Platform Terms *

I agree

HIPAA Compliance Acknowledgment *

I acknowledge

Scope of Practice Acknowledgment *

I acknowledge

Non-Discrimination Agreement *

I agree

Consent to Credential Review *

I consent

Malpractice Insurance Carrier

Policy Number

11. PLATFORM & DIRECTORY SETTINGS

Public Profile Visibility

On

Off

Preferred Contact Method

Platform Messaging

Email

Referral Only

Bio Tagline

Featured Specialties (top 3)

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12. OPTIONAL ENHANCEMENTS (FOR FUTURE GROWTH)

Willingness to Accept Special Referrals

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Interest in workshops or community events

Yes

Interest in content contributions

blogs

panels

webinars

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