Directory Submission Form

If you are a licensed U.S. mental health professional who identifies as an adoptee and works with adoptees / adoptive families in public or private settings, you may use the form below to request adding your information to the Beyond Words Psychological Services Adoptee-Therapist Directory. Only providers who voluntarily submit their own information will be listed.

Note that submissions may take 3-4 weeks to be added to the directory.

I confirm that I am an adopted person. *

Confirm

I confirm that I am fully & independently licensed in the U.S. (not supervised or still counting hours toward licensure). *

Confirm

Name *

First

Last

Business Name *

Website / URL *

Profiles such as Psychology Today, Therapy Den, etc. are acceptable.

Upload copies of all relevant professional state licenses. If you are a member of PSYPACT and would like to be listed under states that have enabled legislation, upload your certificate in addition to your home state license. *

Click or drag files to this area to upload. You can upload up to 10 files.

List the states where you are licensed to provide virtual services below (type "PSYPACT" if you uploaded your certificate above or "N/A" if you do not provide any virtual services): *

If you provide in-person services, list your business address below (type "N/A" in each section if you do not provide in-person services): *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone *

Business Email *

Specialties *

Examples: Trauma, LGBTQIA+, Neurodivergence, EMDR, Brainspotting, Dialectal Behavior Therapy, Internal Family Systems, Search & Reunion, Birth Country Travel Preparation, etc.

Annual Directory Membership Fee *

Your profile will be listed for a period of 1 year from the 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

$100.00

By checking the box below, I confirm that the information I've entered above is true and accurate. I understand that an additional fee will be charged to make any updates or revisions to my profile after this form has been submitted. If I am not eligible to be included and have submitted this form in error, I understand that I will receive a full refund minus a $35.00 administrative fee. If my profile must be removed by the administrator for any reason during my membership period at the administrator's discretion, I understand that I will receive a prorated refund minus a $35.00 administrative fee. *

Confirm

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