The Asian Mental Health Collective (AMHC) Therapist Directory New Provider Application Form
Please check www.asianmhc.org/therapists-us/ for an existing profile before filling out this form. Duplicate submissions will not be considered.

This therapist directory is for Asian mental health providers currently licensed in the US or Canada. The term "Asian" refers to individuals who identify as Asian and include people with ancestry from all parts of Asia, including East Asia, Southeast Asia, South Asia, Central Asia, West Asia (sometimes described as the "Middle East"), Pacific Islanders, and Native Hawaiians. If you do not identify with any of these groups, please consider that this may not be the directory for you.

The information gathered here helps us build a resource for potential clients who might be seeking mental health providers in their area. If your application is accepted, you will be notified of further steps within 4-6 weeks at the email provided. Please be patient as we are always learning more about how this project can evolve and better fit the needs of providers and clients alike.

Approval of this application also serves as approval to be a Therapy Fund provider. Learn more about AMHC's Lotus Therapy Fund here.

If you have any questions, check out our FAQ.

Thank you so much for your interest in being included on our directory. Your work and representation matter greatly.
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Email *
Confirm Log-In Email *
This email is used for directory login username, and must not be a shared email address. This email will NOT be visible on the directory listing.

We highly recommend you make this a personal email rather than a company email whenever possible to ensure you have full control over your listing, regardless of if you remain with your current practice.

e.g.
"ash.ketchum@gmail.com" is preferred over "ash.ketchum@place-of-employment.com"
First Name *
Last Name *
Credentials (Professional Title) *
Please separate multiple credentials with a comma and one space
Ex. LPC, LMHCA, MHC-LP, LCSW, ASW, LMFT, etc.
Note: Student interns and life coaches will not be accepted
Primary License Number *
If you are in a state that does not offer associate/provisional licenses and you have graduated from a master's or doctoral program please enter this note: "No provisional license available in my state" and enter your supervisor's license number below.
Additional License Number(s)
Optional if you have additional license number(s)
Primary License Expiration Date *
MM
/
DD
/
YYYY
Secondary License Expiration Date
Leave blank if you do not have a secondary license.
MM
/
DD
/
YYYY
You must email licensure documentation to licensure@asianmhc.org for approval. 

Use subject line:
AMHC Therapist Directory License Verification - Your Name

Example:
AMHC Therapist Directory License Verification - Ash Ketchum

Failure to use this subject line will result in a delayed or denied application.
 *

Valid licensure must be any piece of attachable media, a link, or forwarded email that clearly shows:
  1. Your name,
  2. Your specific licensure (e.g., LMFT, LCSW, LP, etc.),
  3. The State / Province of licensure.
Supervisor License Number (If an associate licensee or if you work in a state that does not provide associate/provisional licenses, license of supervisor is required. Otherwise put "N/A".) *
Website URL
Phone Number
Please only provide a professional or work phone number that prospective clients may call. If you are not available via phone, leave this field blank.
Country *
AMHC can only accept providers who are based in and are licensed in either the United States or Canada.
US State(s) of Licensure
Canadian Province(s) of Licensure
Self-Identified Ethnic Identity *
Note: Those with no Asian background at all will not be accepted
Required
Primary State/Province (Pick only 1) *
Primary City (Pick only 1) *
Use Full Title Text Format: "San Francisco", "Chicago", "Houston", or "Vancouver"
Primary Zipcode (Pick only 1) *
Values other than U.S. or Canada Zipcodes will not be accepted
Do you acknowledge that the information included in this form is subject to verification of publicly accessible information through state licensing boards in order to protect public safety. * *
Required
Do you acknowledge that the Asian Mental Health Collective reserves the right to pause your participation in this directory if the information provided is not accurate, correct, or licensure status is unable to be verified? *
Required
Do you acknowledge that your practice is not endorsed in any way by the Asian Mental Health Collective and all professional conduct and liability falls within the clinician's ethical and legal obligations of their respective licensing body? *
Required
I would like to opt out of email communications from AMHC. This includes the AMHC newsletter and this may affect communications about future AMHC programming.
A copy of your responses will be emailed to the address you provided.
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