Adoptee-Therapist Directory Requested Revisions Form - Beyond Words Psychological Services

If you are already listed in the Adoptee-Therapist Directory and would like to make revisions to your profile, please complete this form and payment. *

I confirm my understanding that this form is to be submitted only in the event of requesting revisions to a currently listed profile. I understand that revisions must fit the format of the directory.

Name *

First

Last

States under which you are currently listed in the directory: *

Copy & paste your current listing directly from the directory website below: *

Indicate the revisions you would like to request below: *

Example: New contact information, new website, change in population age of clients, additional specialties, additional states of licensure, etc. Note that all revisions must fit appropriately within the categories available on the directory (e.g., insurance is not a listed category, space is not available for bios or narratives, etc.).

If you are requesting to add your listing to new states of licensure, upload an image of your new license(s) below. If you are adding a PSYPACT certificate, upload an image of your APIT certificate below. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Revisions do not constitute a new renewal period for your listing. Your profile will be listed for a period of 1 year from the original date it is added to the directory. A renewal reminder will be emailed to you at least 30 days prior to the end of your listing period. *

I confirm my understanding and agreement with the statement above.

Annual Directory Membership Fee *

Stripe Credit Card *

Total

$0.00