Therapist Locator Submission Form

Therapist/Business Name

Business Setting:

Practice Email:

Practice or Booking Website:

Practice Phone:

Business Location:

Independent Therapist License #:

Therapist/Business Photo:

Upload

Therapist/Business Bio

Tell us about yourself and your practice!

Logo:

Upload

Skills, Services, Specialties

Create a list of:
-services
-skills
-specialties 
you would like listed on your profile.
(Please use bulleted format)

Business Contact Information:

If you are creating a listing for your business. 
Please list the contact information of the owner.
Name:
Email:
Phone:

Blah blah blah - Words about being licensed and being an alumni...