Mental Health + Diabetes Directory Application

Thank you for your interest in applying to be listed in the Mental Health + Diabetes Directory. You must have successfully completed the Mental Health + Diabetes Training Program, be a registered mental health provider in Canada, and currently accepting new clients/patients to be listed. New Directory listings will be added quarterly.

Please fill out the form below. If you have any questions, please contact us at mentalhealthstrategy@breakthroughT1D.ca

Name(Required)

First Name* Last Name*

Are you currently accepting new clients/patients?*(Required)

Yes

Education and Credentials (e.g. PhD, RSW, C Psych)*(Required)

Office Email*(Required)

Office Phone Number*(Required)

Website

Do you want your address hidden in your public profile?*(Required)

Yes

Office Address for Google Maps(Required)

Street Address City Province Postal Code

Provincial Registration Information

Province	Row ID	College/Association	License/registration number	Actions

There are no Entries.

What is your profession? *(Required)

Type of care you provide*(Required)

Adult

Pediatric

Languages spoken (select all that apply)*(Required)

Please specify any other languages you speak*

Separate each language by a comma.

Do you offer virtual appointments?*(Required)

Do you offer direct billing for insurance?*(Required)

Short biography (education, credentials, treatment methods, etc) – please enter in both English and French, if applicable*(Required)

Max 300 words

Upload Headshot Photo

Drop files here or

Accepted file types: jpg, Max. file size: 1 MB, Max. files: 1.

Must be JPG 424 x 424 pixel at 72 resolution. Please re-name your file LastName_FirstName_Biophoto

Upload a copy of your current license/registration*(Required)

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 128 MB, Max. files: 1.

Must be a pdf, jpg or png file, 128mb max. Please re-name your file to LastName_FirstName_ LicenseRegistration

E-mail address used for Mental Health + Diabetes Training Program*(Required)