Adoptee-Therapist Directory Requested Revisions Form Please enable JavaScript in your browser to complete this form.Name *FirstLastStates 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 address 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 (i.e. insurance is not a listed category).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. * Click or drag files to this area to upload. You can upload up to 10 files. Annual Directory Membership Fee *Make revisions to a listing in 1 state or add me to 1 state - $25.00Make revisions to a listing in 2-4 states or add me to 2-4 states - $35.00Make revisions to a listing in 5+ states or add me to 5+ states (non-PSYPACT) - $45.00Make revisions to a PSYPACT listing or add a PSYPACT listing - $95.00Revisions 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 30 days prior to the end of your listing period.Stripe Credit Card *Total$0.00Submit
