Account Type

First Name *

Last Name *

Email Address *

Password *

Gender --Select-- Man Woman Non-Binary

Language(s) That You Speak

Your Photo (This should be a square photo)

How did you hear about us?

Business Phone *

Business Address

City *

Country * --Select-- Canada USA

State * --Select-- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code

City

State --Select-- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Professional designation *

Name of your degree * (For internal use only)

Bio

I offer virtual meetings    I ONLY offer virtual meetings   

Website

Fee Range (Enter from $XXX to $XXX)

Age Range (Choose all that apply) Toddlers / Preschoolers (0 to 6)    Children (7 to 10)    Preteens / Tweens (11 to 13)    Adolescents / Teenagers (14 to 19)    Adults    Elders (65+)   

Counseling Type Couples    Individuals    Family    Groups    Online   

Do you Accept Insurance? Yes    No   

Specialization (Please enter each specialty on a separate line)

Issues ADHD    Addiction    Adoption    Alcohol Abuse    Alzheimer's    Anger Management    Antisocial Personality    Anxiety    Asperger's Syndrome    Autism    Behavioural Issues    Bipolar Disorder    Borderline Personality    Career Guidance    Child or Adolescent    Chronic Illness    Chronic Impulsivity    Chronic Pain    Chronic Relapse    Codependency    Coping Skills    Depression    Developmental Disorders    Disabled    Divorce    Domestic Abuse    Domestic Violence    Drug Abuse    Dual Diagnosis    Eating Disorders    Emotional Disturbance    Family Conflict    Gambling    Grief    Hoarding    Infertility    Infidelity    Intellectual Disability    Internet Addiction    Learning Disabilities    Life Coaching    Life Transitions    Marital and Premarital    Medical Detox    Medication Management    Men's Issues    Narcissistic Personality    Obesity    Obsessive-Compulsive (OCD)    Oppositional Defiance    Parenting    Peer Relationships    Pregnancy    Prenatal    Postpartum    Racial Identity    Relationship Issues    School Issues    Self Esteem    Self-Harming    Sex Therapy    Sexual Abuse    Sexual Addiction    Sleep or Insomnia    Spirituality    Sports Performance    Stress    Substance Abuse    Suicidal Ideation    Teen Violence    Testing and Evaluation    Transgender    Trauma and PTSD    Traumatic Brain Injury    Video Game Addiction    Weight Loss    Women's Issues   

Social Media Permission I give permission to the blacktherapistlist.com to post my photo and other profile information on other social media pages for greater exposure of my profile   

My Instagram Username

If you provide group counseling, please enter the group name below

If you offer group counseling, please enter the group description below

How did you hear about us? i.e. Google search, Facebook Ad, a friend, an Ad?

* I identify as black