Level Therapy Provider Application
Fill out our short form to begin the application process.
Let's go!
 
Thanks for your interest in joining.

What's your full name? *

 
Let's talk about licensure.

Are you licensed to practice? *

     
 
Which state?

 
What is your license number?

 
What is your License Title? (Ex. LMFT, LPPC, etc.) *

 
How long have you been practicing? *

 
With which population do you prefer to practice? *

 
What do you consider your areas of specialization? *

 
What is your email address? *

We need this to follow up if we are interested. We will NEVER spam you or give your email to anyone else.