Provider Application

First Name *

Last Name *

Email Address *

Phone Number *

Professional Title *

Practice Name

Website

License Type *

License Number *

Licensing State *

Years in Practice *

Telehealth Available

In-Person Available

Office City

Office State

Languages Spoken

Insurance Accepted

Currently Accepting New Clients

Professional Biography *

Why do you want to join BLKMYNDZ? *

What does culturally affirming wellness and healing mean to you? *

How do you create a safe and inclusive environment for the communities you serve? *

What populations do you feel most called to serve? *

How did you hear about BLKMYNDZ? *

Upload Headshot *

JPG, PNG, or WebP only. Max 5MB.

I certify all information is true and accurate.

I authorize BLKMYNDZ to verify my professional license.

I authorize BLKMYNDZ to conduct a National Sex Offender Registry search.

I authorize BLKMYNDZ to conduct an OIG exclusion search.

I understand submission does not guarantee approval.

I have read and agree to the Provider Agreement

I have read and agree to the Terms of Service

I acknowledge the Privacy Policy

I have reviewed the Verification & Credentialing Policy