Name(Required)

First Last

Email (For internal purposes only, your email will not be published in the resource book.)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Company Name

Website

Credentials(Required)

In what year were you licensed?(Required)

How do your clients pay for your services?(Required)

Client self-pay (Cash, check, credit, PayPal, Zelle, through website, telehealth platform, or in-person)

Insurance

If you answered "Client self-pay" in the previous question, please include methods here.

Do you accept insurance? If so, please specify which providers you are in-network with:(Required)

Resource Book Information Submission

Do you provide mental health resources in the Houston area?