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Apply to Be a DSI Provider
Fill out the form below to be added to the No More Gatekeeping provider list.
Name
(Required)
First
Pronoun(s)
(Required)
Please write pronouns such as (she) or (she | they)
Headshot
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Add a picture if you want, but this is optional
Email
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Phone
Website
Please capitalize every word in the web address for accessibility. Ex: VanEthanLevy.com
Where are you located?
City & State
Meeting Type
(Required)
In Person
Virtual
Check all that apply
State you're licensed in
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Alabama
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Licensure
(Required)
Psychologist/PsyD
Medical Provider
Psychiatrist
Licensed Therapist
Therapist
Therapist = Trainee, Associate, Practicum, Intern, or Unlicensed
Insurance Accepted
(Required)
Yes
No
Insurance Providers
Aetna
Allianz
Blue Cross
Blue Shield
Cigna
Kaiser
Molina
United Healthcare
Another insurance not listed
Languages spoken for assessments
(Required)
American Sign Language (ASL)
Arabic
Cantonese
English
French
German
Hebrew
Hindi
Italian
Japanese
Korean
Mandarin
Portuguese
Russian
Spanish
Tagalog
Thai
Vietnamese
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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