Provider Info
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Provider Name: *
Email:  *
Degrees/Credentials:  *
Gender:  *
Personal Pronouns: 
Race/Ethnicity:  *
Faith:  *
Languages Spoken (besides English):
In which state(s) are you licensed to practice? *
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Company/Clinic/Practice Name:
Website:  *
Phone Number:  *
Clinical Specialties:  *
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Client Age Focus:  *
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Are you accepting new clients for in-person sessions? *
Are you accepting new clients for online sessions? *
Fees:  *
Do you offer sliding scale pricing？ *
Please select all the payment methods that you accept: *
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If you're in-network with any insurance companies, select them here.
Do you accept clients claiming on their Out-Of-Network benefits?
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