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Apply: Provider Interest Form

Welcome to The List - a curated network connecting women to trusted, vetted wellness providers.

Thank you for your interest in being part of the The List. This form helps us learn more about your practice, understand your areas of expertise and review alignment as we continue building our provider community.

Women who come through The List are intentional in seeking support and are guided toward providers who align with their needs and values. Your responses below allow us to thoughtfully review your work and better understand how your practice may fit within the network.

Full Name

Business/Practice Name

Email

Where are you based/where do you practice?

Where are you based/where do you practice?

If other, where?

Website

Social media handle

Primary Specialty

Primary Specialty
A
B
C
D
E
F
G

If you selected other, please share what industry/category here:

Do you offer in-person, virtual or both?

Do you offer in-person, virtual or both?

Are you currently accepting new clients?

Are you currently accepting new clients?
A
B
C

Do you accept insurance? If so, please select which plans

Do you accept insurance? If so, please select which plans

If you accept other insurance providers, please list here

In a sentence or two — what makes your approach or practice unique?

Very soon The List will become a paid provider membership that includes visibility in a member-facing directory, access to a community for providers and potential to be personally referred to women looking for support. Does this align with what you’re looking for?

Very soon The List will become a paid provider membership that includes visibility in a member-facing directory, access to a community for providers and potential to be personally referred to women looking for support. Does this align with what you’re looking for?
Submitting this form expresses your interest in being part of The List. While inclusion does not guarantee client referrals, all applications are thoughtfully reviewed as we expand our provider roster. Selected providers will receive additional details regarding participation and membership options.