Mental Health Professional Listing Form - Parkinson's Association of San Diego

Name(Required)

First Last Postnomials (PhD, LCSW, MSW, etc.)

Professional Title(Required)

Clinical Psychologist

Marriage and Family Therapist

Licensed Clinical Social Worker

MSW

Other

If other professional title, please note:

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Photo for the Website(Required)

Accepted file types: jpg, jpeg, png, bmp, pdf, heic, Max. file size: 20 MB.

I am licensed to practice in the following states:(Required)

California

Other

If licensed in other states, please note:

I will practice via (check all that apply):(Required)

Telemedicine

In person

If in person, what region in San Diego do you see clients?

Payment Methods(Required)

I accept insurance including medicare

I am cash pay

I am cash pay and will provide a super bill on request

Any other notes about your payment methods?

Short Bio for the Website(Required)

Any other notes for us?