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Applications are not open yet. This form is for review only. Nothing is submitted until our secure intake system is connected.

Provider Application

Tell us about your practice. Your application is reviewed before anything goes live. Licensing details are used only for verification and are never shown publicly. Every listing starts with a 30-day free trial. Only verification details are required, and everything else is optional.

  1. 1Your details
  2. 2Licensing and location
  3. 3Services
  4. 4Your profile
  5. 5Agreements
1. Identity and Contact

How you will appear in the directory.

Used for verification and communication. Not displayed publicly.
Used for verification. Not displayed publicly.
Shown on your profile as a link. Must start with https://.
An office line or business inbox works well. Phone and email appear only if you check the boxes above. You can change this later.
2. Licensing (private)

We verify these with the state board and the NPPES registry. They are never displayed on your profile.

3. Practice Location

Only city, state, and ZIP appear publicly. Your full street address stays private.

Used for verification and map placement only. Never displayed publicly.
4. Insurance

Select only panels where you are currently in-network. Options match the directory filters.

Panels not in the directory filters are saved for review but won't appear in search until added.
5. Fees (optional)
6. Specialties

Select up to six areas you focus on.

7. Clients Served
8. Availability
9. In Their Own Words

Written by you, in your own words. Between 200 and 1,500 characters. Three short paragraphs work well. Optional, but a clear statement helps clients decide.

0 / 1,500
10. Photos and Video (optional)

Help clients feel they know you before they reach out. A short intro video and a few photos of your space or your work go a long way.

Keep it under two minutes. Unlisted links work. Only YouTube and Vimeo links are accepted.
Show your space or your work. Do not include clients, patients, or identifying documents.
If you skip the headshot, a placeholder avatar is used. You can add video and photos later.
11. Identity Information (optional)

This is entirely optional. Share only what you choose. It is never shown publicly unless you check the box below. Our "built by and for Black clinicians" standard is confirmed through this section and your attestation.

12. Attestation and Consent

Monthly price and cancellation details will be published here before billing opens. Nothing is charged until then.