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Tell Us About Yourself
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Tell Us About Yourself
Tell us about yourself
Please note that some or all of the information provided will be used on the "Find a Provider" page on Spacekansascity.com to promote you and your practice. We will never sell or list your information to a third party. Please let us know if you have any questions or would like to exclude any of the required information.
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Name
*
First
Last
Credentials / Licensure
*
Education
*
Business Phone
*
Business Email
*
Website (if applicable)
Accepting New Clients?
*
Yes
No
Insurances Accepted (if applicable, please separate with a comma)
Private Pay Range
Sliding Scale?
*
Yes
No
Ability to conduct sessions via tele-health in Missouri?
*
Yes
No
Specialties (please separate with a comma)
*
Second-Tier Specialties (please separate with a comma)
Therapeutic Modalities (please separate with a comma)
Client Demographics (check all that apply)
Male
Female
Millenial
LGBTQIA
Couples
Marriage
Child
Hispanic
African American
Business
Other (we will contact you for these)
Groups / Organizations you Belong to (if applicable, please separate with a comma)
Tell us about yourself. This can be your bio, a description of your therapeutic approach, whatever you think a prospective client would find valuable to better understand the kind of therapist you are.
*
What do you do to get Space? (get a massage, try local restaurants, take a nature walk, etc.)
Submit
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