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LGBTQIA+ Affirming Providers
Thank you for helping Authentic Roots Therapy better serve our community!
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Email
*
Your email
Clinic Name
*
Your answer
Therapist Name
*
Your answer
Pronouns
*
Your answer
Website
Your answer
Address
*
Your answer
Phone
*
Your answer
Do you offer telehealth care?
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Yes
No
Do you offer in-person care?
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Yes
No
Other:
Do you accept insurance?
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Yes
No
If accepting insurance, who are you in network with?
Your answer
Current availability?
*
Please continue to log in to this form(with same email) and keep your availability up-to-date.
Immediate availability
Availability but a few weeks/month out
Waitlist only
Not taking any referrals
Other:
A copy of your responses will be emailed to the address you provided.
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