Provider Application Form - Manhattan Alternative

Please note: There is currently a waiting list that is constantly being reordered to move POC and people with multiply intersecting identities to the top. Listing priority is also given to those who know personally and are referred by an existing ManhattanAlternative.com provider, and who have multiple personal connections to the communities we serve. Finally, because I maintain this website myself as a labor of love, I sometimes have to put listing additions on the back burner altogether due to other obligations. Timing for publishing new listings can vary widely, from the same day to several weeks or longer. I try to respond to every inquiry and follow up email but I am not always able to; please don't take it personally.

Name (as you would like it to appear on the site)*

Degrees/Licenses/Certifications (must be directly associated with/in support of the profession you are listing)*

Are you licensed in New York? (Only providers with practices based in NY are listed on the site.)*

Yes
No

If your license requires that you practice under supervision (e.g., LMSW), please indicate the name and email address of your supervisor for confirmation (I will send a brief email to confirm):

Title (this will appear under your name on the main page; e.g., psychotherapist, psychologist, psychiatrist, etc)*

Subtitle/Specialization (this will appear under your title on the main page; usually keywords indicating your areas of focus, specific populations, treatment approaches, etc; see other profiles on the main page for examples)—please note that this line has a maximum of about 32 characters including spaces*

Website (must be to your web or profile page, not a general practice page (unless you're the only person at the practice))*

Email (must be a direct email, not a general practice email)*

Phone (must be a direct phone number, not a general practice phone number; if you'd rather not list your phone number on your profile, please include something else for this field in order to fit the template, such as another page on your website, a different website, or a social media handle)*

Facebook Page (optional)

LinkedIn Profile URL (optional)

Please include a 100 (minimum) to 125 (maximum) word bio for your individual profile page.*

Upload Photo: Must be a minimum of 640x640 dpi, and maximum 64 MB file size. It's fine to submit photos larger than 640x640 (and up to 64 MB); they will be cropped and downsized to fit. Please do not submit photos with original dimensions smaller than 640x640, as they may be blurry/too pixelated.*

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 256 MB.

Who referred you to ManhattanAlternative.com? (Please note I will send a brief email to confirm, and listing priority is given to those who are referred by someone already on the site.)*

Please indicate the provider category filter(s) you would like to be included in (must have related credentials to be included in the therapist, psychiatrist/medication management, and health care provider categories):

POC-identified provider
therapist
sex therapist
psychiatrist
alternative healer
trainer/coach

Please indicate the category filter(s) you would like to be included in:

Please list any insurance panels you're in-network with here:

Please indicate whether you are or have been personally affiliated with any of the following identities/communities/practices:

BDSM/kink
CNM/poly
LGB/queer/non-straight
GNC/trans
current/former sex worker

How has your personal experience impacted your kink/poly/trans/LGBQ clinical competence?*

If you identify as an ally to one or more of these communities, how do you practice being kink/poly/trans/LGBQ-affirmative and -competent?*

Do you lack clinical competency in any areas related to non-mainstream (i.e., kink, poly, CNM, LGBQ, trans, GNC, etc) identifications, communities, and/or practices? If so, what are they, and how are you working toward improvement in those areas?*

Please describe your reason(s) for wanting to work with kink/poly/trans/LGBQ-identified individuals.*

Please describe any work you have done directly with LGBTQ-identified, kink-identified, and/or poly-identified people and communities.*

Please list any publications you’ve authored/co-authored relating to these populations.

Please list any conference presentations or facilitation of clinical seminars relating to these populations.

If your profile is listed, would you like to be added to the Manhattan Alternative Providers Listserv? If yes, please enter your preferred listserv email address. If no, please enter N/A.*

Non-exploitation agreement*

I agree to follow Community Guidelines, and to avoid any behavior that would exploit community members, supervisees, employees, and colleagues.

Please read and follow ManhattanAlternative.com/community-guidelines; if the guidelines are not followed, you will be removed from the site.

Consent*

I agree to the privacy policy.

Please read ManhattanAlternative.com/privacy-protocol to learn about steps taken to ensure your information is kept private.

Name

This field is for validation purposes and should be left unchanged.