List Your Practice Participants Database Signup

First Name*

Last Name*

Credentials*

Please list the initials to be included after your name (PhD, MA, LCSW, etc)

Country*

State / Territory*

City / Locality*

Street Address

Postcode*

Time Zone*

Email*

Phone*

Languages*

Name of Practice*

Profession*

Licensure or Certification Verification

Please enter web site where we can verify your license or certification.

Alternate form of verification – upload an image of your license or certification

File must be 2MB or smaller.

Age Group Focus*

Children Adolescents Adults Seniors

Your Photo*

Profile Background Picture

Treatment Approaches

Faith Focus?

Sexuality Focus?

Straight LGBTQ

Top Three Areas Specialties

All Areas of Focus

Years of Experience

Type of Session?

Individuals Groups Couples Families

Short Biography

Website Link

Which States?

United States Terms and Conditions

I agree to practice online counselling only within the state that I am licensed. (i)

Terms and Conditions*

I accept the terms and conditions.