Clinician Application

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Therapist-Clinician Form

This form is for individual therapists, psychologists, psychiatrists, and certified life coaches that work with youth to list their services in the YouthWell directory. Once approved, we will reach out to you so you can add your listing to the directory.

"*" indicates required fields


Please share the link to your website if you have one.
Work Address
If you are part of a group practice, please put the NAME OF the GROUP or BUSINESS. If you work independently, please put INDEPENDENT.


Please include any degrees and the licenses you hold.
What is your license # if you are a licensed clinician? Put N/A if it does not apply.
Please share what type of clinician you are. If OTHER, please specify in the comments area below.
How many years do you have specifically working with youth, ages 5-25 in your practice (including your internship/residency/post-doctoral)?


Please let us know if you currently have a waiting list. This helps us to know if we are making a referral.
What areas of Santa Barbara County do you serve?
Do you provide telehealth counseling services? Please choose "on occassion" if this is not common in your practice.
Ages served*
Please share what ages you serve in your practice.
Do you speak, English, Spanish or are you bilingual?
Please list any specialties related to youth and families. Do you do EMDR, play therapy, bereavement/grief, sexual assault, eating disorders, substance use, etc.


Do you provide a sliding scale for fees in your practice?
Do you take insurance? And if no, do you provide a superbill so that individuals can submit on their own?
Please specify your overall rates for providing services. If you offer a sliding scale, please specify those rates as well.