How to Submit a Provider Profile


Provider Profile Submission Instructions:

  1. Copy/paste the template below into an email. Complete all template items.
  2. Use the camera on your computer to record a short video introducing yourself. Verbally address each item on the template. (A self-introduction video is strongly recommended but not required. It is appropriate to submit a written provider profile now and a self-introduction video later.)
  3. Upload your self-introduction video to YouTube and copy/paste its URL into the space provided at the end of the template.
  4. Tell us if you are interested in blogging at Mormon Mental Health and/or if you are interested in recording Mormon Mental Health podcasts on your areas of specialty.
  5. Email the completed template including the link to your YouTube provider self-introduction (if applicable) and a photo of yourself to


Provider Profile Template:

Name (including credentials):
Institution(s) where you trained:
State(s) in which you are licensed:
Number of years you have practiced:
Where you practice:
Long-distance Skype or Internet services available (y/n):
Acceptance of some insurance plans (y/n):
Hourly rate for clients not using insurance:
Your Mormon background:
Your experience practicing mental health within a Mormon cultural context:
Issues you are qualified to address:
Mental health disorders you are qualified to treat:
Contact information:

URL of your YouTube provider self-introduction:

Are you interested in blogging at
Would you be interested in recording podcasts about your areas specialty for Mormon Mental Health?

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