Service Provider Application

Select An Option

Service Provider Membership--Tier I $120 Annually

Tier I Affiliate listing on our referral database and public directory
Logo, picture, web link, and other personalization options
Up to 10 individual therapists listed

Service Provider Membership - Tier II $250 Annually

Tier II Affiliate listing on our referral database and public directory
Logo, picture, web link, and video personalization options
Up to 40 individual therapists listed

Service Provider Membership - Tier III $500 Annually

Tier III Affiliate listing on our referral database and public directory
Logo, picture, web link, and video personalization options
Unlimited individual therapists listed
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Enter Contact Information

Prefix (i.e. Mr. Mrs. Dr.)

First Name

Last Name

Suffix (i.e Jr. Sr. III)

Designations

E-mail

Family NameBusiness Name

Please select a valid membership option and fee item if exist