THE ASSOCIATION OF BLACK PSYCHOLOGISTS

KATRINA EMERGENCY MENTAL HEALTH CARE PROVIDERS REFERRAL REGISTRATION 

In an effort to provide cultural relevant mental health services to survivors of Hurricane Katrina, ABPsi is compiling a list of mental health care volunteers.  Providers must be willing to provide service, at no cost, to those survivors without resources, for a period of at least three (3) months. Those wishing to participate please fill out the registration form below.

To participate, please complete this online registration form or download a form and mail/fax us your information.

To be included on our referral service, you are required to be authorized to practice by the jurisdiction where you will provide services. If you are a support association or faith based organization, which provides counseling services, please submit this form and download our resource referral form to be included as a community resource.

ABPsi Psychologist Directory Registration Form
First Name
MI
Last Name
 Suffix(es): Ph.d., Psy.D., MFCC, LICSW, LMFT,etc
Address:.
City:.
State:.
.Zip:.
Phone:.
.Ext:.
E-Mail:.
STATE LICENSURE
STATE/NATIONAL CERTIFICATION
Are you Licensed?  ... Are you Certified?
If yes, in what profession(s)? If yes, in what specialty(ies)?
State(s) Licensed:
License No & Expiration:
State(s) Certified:
Certification No. & Expiration:
Nat'l Certification(s) :
Certification No. and Expiration:
Please indicate areas of specialty.  (Check all that apply)
Post Trauma
Sexual Abuse
Chemical Dependency
Crisis Intervention
HIV/AIDS
Intellectual Assessment
Depression / Anxiety
Veterans
Personality Assessment
Grief / Death & Dying
GLBT
Health Psychology
Children Therapy
Testing
Educational / School
Adolescent Therapy
Clinical / Counseling Psychology
Couples/Family Therapy
Gerontological Therapy
Please indicate age groups covered by your practice.  (Check “All Age groups” or all that apply)
All Age Groups
Adolescents (13-17)
Adults (21-54)
Early Childhood (2-12)
Young Adults (18-21)
Seniors (55-up)
Personal Information (optional):
Willing to go there!
MENTAL
 HEALTH CARE 
PROVIDERS NEEDED
MENTAL
 HEALTH CARE 
PROVIDERS NEEDED
The Association of Black Psychologists P.O Box 55999, Washington, D.C.20040. Phone: (202) 722-0808 Fax: (202) 722-5941. Managed by Walk-OnLine