Provider Application Form | Manhattan Alternative

Name*

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

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

Title (e.g., psychotherapist, psychologist, psychiatrist, etc)*

Specialization/2nd Title (e.g., areas of focus, specific populations, treatment approaches, etc)*

Phone*

Email*

Website*

Facebook Page (optional)

LinkedIn Profile URL (optional)

Insurance(s) Accepted (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.*

Who referred you to ManhattanAlternative.com?*

NOTE: Listing priority is given to those who know personally and are referred by an existing ManhattanAlternative.com provider. If you have been referred by an existing ManhattanAlternative.com provider, please list their name here so they can be contacted to verify your connection.

Please indicate your population(s) of expertise (choose all that apply):

Please indicate whether you are personally affiliated with any of the following identifications/communities/practices (choose all that apply):

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.*

Comments

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