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Join the You & Me Too Therapist Network

We are building a thoughtful, survivor-centered network of trauma-informed professionals who align with our mission of offering compassionate support to survivors of sexual, physical, and emotional abuse.

This form allows us to learn more about your background, approach, and interest in future referral or collaboration opportunities.

At this stage, we are gathering information and building relationships intentionally. Submission of this form does not guarantee inclusion in the network.

Important: Providers included in this network are independent professionals and are not employees, agents, contractors, or representatives of the You & Me Too Foundation. The Foundation does not provide clinical services, supervise treatment, or assume responsibility for therapeutic relationships or outcomes. Any services are arranged directly between the provider and the individual seeking support.

1. Full Name

2. Credentials / Professional Designation

Example: LMFT, LPC, LCSW, PsyD, PhD, MD

3. License Number

4. State(s) of Licensure

5. Practice or Organization Name

6. Website

7. Professional Email Address

8. Phone Number

Your Practice

9. What type of provider are you?

9. What type of provider are you?
A
B
C
D
E
F

10. If you selected Other, please specify your professional role

11. How do you currently offer services?

11. How do you currently offer services?

12. Where is your practice based?

City, State

14. Which populations do you primarily serve?

14. Which populations do you primarily serve?

15. If you selected Other, please specify

16. What are your primary areas of specialization?

Please share the main concerns, experiences, or needs you most often support in your work.

17. Which therapeutic modalities or approaches do you use?

Which therapeutic modalities or approaches do you use?
17. Which therapeutic modalities or approaches do you use?

18. If you selected Other, please specify

19. How would you describe your approach to trauma-informed care?

ACCESSIBILITY & FIT
We want this future network to reflect care that is safe, accessible, and responsive to different survivor needs.

20. Do you offer sliding scale rates?

20. Do you offer sliding scale rates?
A
B
C

21. Do you accept insurance?

21. Do you accept insurance?
A
B
C

22. If yes, please list the insurance plans you accept

23. Are you open to receiving referrals for clients seeking trauma-informed support?

23. Are you open to receiving referrals for clients seeking trauma-informed support?
A
B
C

24. Are there any populations, concerns, or treatment areas that fall outside your scope of practice?

COLLABORATION INTEREST

25. In addition to possible referrals, would you be open to future collaboration opportunities with the Foundation?

25. In addition to possible referrals, would you be open to future collaboration opportunities with the Foundation?

26. What draws you to the You & Me Too Therapist Network?

ACKNOWLEDGMENT AND CONSENT

Please review and confirm each statement below before submitting your form.

Please review and confirm each statement below before submitting your form.

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28. Typed Full Name

Date