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Therapist Directory Intake Form
Section 1: Contact & Profile
1. Full Legal name & Name Licensure is held in
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2. Pronouns
3. Photo upload
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Click to choose a file or drag here
Size limit: 10 MB
4. Preferred contact method for potential clients: website URL or email address
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5. Contact information for follow-up questions
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Section 2: Credentials
6. License type
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7. License number
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8. State of licensure
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9. License Expiration Date
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10. Additional states, license types, license numbers, and expiration dates.
(Example: New York, LCSW, 12345, 07/27/2027)
11. Years in practice
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