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Provider Directory
Provider Application
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Contact
Provider Directory
Provider Application
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DSI Provider Directory Submission
This is the internal DSI team form to add a provider to the No More Gatekeeping list.
Name
(Required)
First
Pronoun(s)
Please write pronouns such as (she) or (she | they)
Headshot
Max. file size: 1 GB.
Add a picture if you want, but this is optional
Email
(Required)
Phone
Website
Copy and paste the website link from your browser so the link starts with https:// and then please capitalize every word in the web address for accessibility. Ex: https://VanEthanLevy.com
Where are you located?
City & State
Meeting Type
In Person
Virtual
Select all that apply
States you're licensed in
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select all that apply
Licensure
Psychologist/PsyD
Medical Provider
Psychiatrist
Licensed Provider and/or Therapist
Provider and/or Therapist
Provider and/or Therapist = Trainee, Associate, Practicum, Intern, or Unlicensed
Pricing
Free ($0)
Low Fee ($50 or less)
Sliding Fee ($1-100)
Full Fee ($100 or more)
Accepts Insurance
Select all that apply
License number and supervisor (if applicable)
Insurance Providers
Aetna
Allianz
Anthem
Blue Cross Blue Shield
Cigna
Kaiser
Medicare/Medicaid
Molina
United Healthcare
Another insurance not listed
N/A
Languages spoken for assessments
American Sign Language (ASL)
Arabic
Bosnian
Cantonese
Croatian
English
French
German
Hebrew
Hindi
Hmong
Italian
Japanese
Korean
Mandarin
Persian
Portuguese
Russian
Serbian
Spanish
Tagalog
Thai
Vietnamese
I offer interpretation services
If a language you speak is missing, please email NoMoreGatekeeping@gmail.com so we can add it to the list.
I will write people letters to start hormones and/or have surgery after 1 assessment/session
(Required)
I agree
I will write a letter for a gender marker and/or name change for IDs, driver's licenses, and passports
(Required)
I agree
Phone
This field is for validation purposes and should be left unchanged.
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