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Mental Health Application
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Mental Health Application
My ATL Black Doctor Directory Application - Mental Health
Name
(Required)
First Name
Last Name
What is your age?
(Required)
Under 35
35 to 45
45 to 55
greater than 55
How do you want your name(including credentials) to appear in the directory?
(Required)
Did you graduate from an HBCU?
(Required)
Please Select
Yes
No
Where did you go to graduate school?
What HBCU did you attend?
(Required)
Select State
Alabama
Arkansas
Delaware
District of Columbia
Florida
Georgia
Kentucky
Louisiana
Maryland
Michigan
Mississippi
Missouri
North Carolina
Ohio
Oklahoma
Pennsylvania
South Carolina
Tennessee
Texas
US Virgin Islands
Virginia
West Virginia
Alabama
(Required)
Please Select
Alabama A&M University- Huntsville
Alabama State University- Montgomery
Concordia University-Alabama- Selma (closed 2018)
Gadsden State College- Gadsden
J.F. Drake State Technical College- Huntsville
Lawson State Community College- Birmingham
Miles College- Fairfield
Miles School of Law- Fairfield *
Oakwood University- Huntsville
Selma University- Selma
Shelton State Community College- Tuscaloosa
Stillman College- Tuscaloosa
Talladega College- Talladega
Tuskegee University- Tuskegee
H. Councill Trenholm State Community College Montgomery
Arkansas
(Required)
Please Select
University of Arkansas at Pine Bluff- Pine Bluff
Arkansas Baptist College- Little Rock
Philander Smith College- Little Rock
Shorter College- North Little Rock
Delaware
(Required)
Please Select
Delaware State University- Dover
District of Columbia
(Required)
Please Select
University of the District of Columbia
Howard University
Florida
(Required)
Please Select
Bethune Cookman University- Daytona Beach
Edward Waters University- Jacksonville
Florida A&M University- Tallahassee
Florida Memorial University- Miami Gardens
Georgia
(Required)
Please Select
Albany State University- Albany
Carver College*- Atlanta
Clark Atlanta University- Atlanta
Fort Valley State University- Fort Valley
Interdenominational Theological Center- Atlanta
Johnson C Smith Theological Seminary*- Atlanta
Morehouse College- Atlanta
Morehouse School of Medicine- Atlanta
Morris Brown College- Atlanta
Paine College- Augusta
Savannah State University- Savannah
Spelman College- Atlanta
Kentucky
(Required)
Please Select
Kentucky State University- Frankfort
Simmons College of Kentucky- Louisville
Louisiana
(Required)
Please Select
Dillard University-New Orleans
Grambling State University- Grambling
Southern University and A&M College- Baton Rouge
Southern University New Orleans- New Orleans
Southern University-Shreveport- Shreveport
Xavier University- New Orleans
Maryland
(Required)
Please Select
Bowie State University- Bowie
Coppin State University- Baltimore
University of Maryland- Eastern Shore- Princess Anne
Morgan State University- Baltimore
Michigan
(Required)
Please Select
University of Arkansas at Pine Bluff- Pine Bluff
Arkansas Baptist College- Little Rock
Philander Smith College- Little Rock
Shorter College- North Little Rock
Mississippi
(Required)
Please Select
Alcorn State University- Lorman
Coahoma Community College- Clarksdale
Hinds County Community College- Utica
Jackson State University- Jackson
Mississippi Valley State University- Itta Bena
Rust College- Holly Springs
Tougaloo College- Tougaloo
Missouri
(Required)
Please Select
Harris-Stowe State University- St. Louis
Lincoln University- Jefferson City
North Carolina
(Required)
Please Select
Barber-Scotia College**- Concord
Bennett College- Greensboro
Elizabeth City State University- Elizabeth City
Fayetteville State University- Fayetteville
Hood Theological Seminary*- Salisbury
Johnson C. Smith University- Charlotte
Livingstone College- Salisbury
North Carolina Central University- Durham
North Carolina A&T State University- Greensboro
Shaw University- Raleigh
St. Augustine's University- Raleigh
Winston-Salem State University- Winston Salem
Ohio
(Required)
Please Select
Central State University- Wilberforce
Payne Theological Seminary*- Wilberforce
Wilberforce University- Wilberforce
Oklahoma
(Required)
Please Select
Langston University- Langston
Pennsylvania
(Required)
Please Select
Cheyney University- Cheyney
The Lincoln University- Lincoln University
South Carolina
(Required)
Please Select
Allen University- Columbia
Benedict College- Columbia
Claflin University- Orangeburg
Clinton College- Rock Hill
Denmark Technical College- Denmark
Morris College- Sumter
South Carolina State University- Orangeburg
Voorhees University- Denmark
Tennessee
(Required)
Please Select
American Baptist University- Nashville
Fisk University- Nashville
Knoxville College**- Knoxville
Lane College- Jackson
LeMoyne Owen College- Memphis
Meharry Medical College
Tennessee State University- Nashville
Texas
(Required)
Please Select
Huston-Tillotson University- Austin
Jarvis Christian College- Hawkins
Paul Quinn College- Dallas
Prairie View A&M University- Prairie View
Southwestern Christian College- Terrell
St. Philip's College- San Antonio
Texas College- Tyler
Texas Southern University- Houston
Wiley College- Marshall
US Virgin Islands
(Required)
Please Select
University of the Virgin Islands- St. Thomas & St. Croix
Virginia
(Required)
Please Select
Hampton University- Hampton
Norfolk State University- Norfolk
Saint Paul's College- Lawrenceville (closed 2013)
Virginia State University- Petersburg
Virginia Union University- Richmond
Virginia University of Lynchburg- Lynchburg
West Virginia
(Required)
Please Select
Bluefield State College- Bluefield
West Virginia State University- Institute
If you did not attend an HBCU, where did you go to college?
(Required)
What is your specialty? (Select all that apply)
Child Psychiatry
Adolescent Psychiatry
Geriatric Psychiatry
Forensic Psychiatry
Addiction Psychiatry
Did you do a fellowship?
(Required)
Yes
No
In what subspeciality did you do your fellowship?
(Required)
Are you Board Certified?
(Required)
Yes
No
Do you have a current license to practice medicine in the state of Georgia?
(Required)
Yes
No
Are you currently clinically active and seeing patients?
Please Select
Yes
No
If you are taking appointments, please provide the link to your appointment and scheduling platform.
(Required)
Type of practice or healthcare system you are employed by. Check all that apply.
Medical School Faculty
Healthcare System
Private/Group Practice
Corporate/Industry
Government
Healthcare System
(Required)
Please Select
Morehouse School of Medicine/Morehouse Healthcare
Emory University School of Medicine/Emory Clinic
Piedmont Healthcare
Grady Health System
Children’s Healthcare of Atlanta
WellStar Medical Group
VA Hospital
Kaiser Permanente
Northside Hospital
Dekalb Medical Physicians Group
Cancer Treatment Centers of America
Private/Group Practice
(Required)
Please Select
Laureate Medical Group
Resurgens Orthopedics
Atlanta Gastroenterology
Thomas Eye Group
Atlanta Women’s Health
Family Health Centers of Georgia
Southside Medical Center
The Longstreet Clinic
Other
Please mention other Practice
(Required)
Corporate/Industry
(Required)
Company Name
Government
(Required)
Agency or Organization Name
Practice Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Select all cities where you have a practice location.
Atlanta
Acworth
Alpharetta
Austell
Avondale Estates
Buford
Canton
Carrollton
Chamblee
Clarkston
College Park
Conyers
Covington
Cumming
Dacula
Dallas
Decatur
Doraville
Douglasville
Duluth
Dunwoody
East Point
Fairburn
Fayetteville
Forest Park
Griffin
Hampton
Hiram
Jonesboro
Kennesaw
Lawrenceville
Lilburn
Lithia Springs
Lithonia
Locust Grove
Loganville
Lovejoy
Mableton
Marietta
Mcdonough
Morrow
Newnan
Norcross
Peachtree City
Powder Springs
Riverdale
Roswell
Sandy Springs
Senoia
Sharpsburg
Smyrna
Snellville
Stockbridge
Stone Mountain
Sugar Hill
Suwanee
Tucker
Tyrone
Union City
Villa Rica
Vinings
Winder
Woodstock
Facebook
ie. https://www.facebook.com/myabb
Instagram
ie. https://www.instagram.com/myabb
Facebook
ie. https://www.facebook.com/myabb
Facebook
ie. https://www.facebook.com/myabb
Website
ie. https://www.mybdd.com
Other
ie. https://...
LGBTQIA+ Friendly Practice
Please Select
Yes
No
Prefer not to answer
How many years have you been practicing?
(Required)
Please Select
less than 10 years
10-25 years
greater than 25 years
Memberships
Sororities
(Required)
Please Select
N/A
Alpha Kappa Alpha
Delta Sigma Theta
Sigma Gamma Rho
Zeta Phi Beta
Fraternities
(Required)
Please Select
N/A
Alpha Phi Alpha
Iota Phi Theta
Kappa Alpha Psi
Omega Psi Phi
Phi Beta Sigma
Are you a member of any of the following organizations?
(Required)
Atlanta Medical Association
Georgia State Medical Association
National Medical Association
Student National Medical Association
None of the above
Other
Other
(Required)
Are you a member of any other nationally based social organizations? (Select All That Apply)
(Required)
Jack and Jill of America
The Links, Incorporated
100 Black Men Of America, Inc.
100 Black Women of America, Inc.
N/A
Other
Other
(Required)
Are you a member of any specialty based professional organizations, eg. American College of Surgeons
GETTING TO KNOW YOU
Do you have any other professional degrees?
(Required)
N/A
MBA
MPH
MHA
MPA
PHD
JD
Other
Do you have any additional professional certificates or awards?
Do you have any unique talents, experiences, or accomplishments?
Have you won any professional, humanitarian, or other significant awards?
Do you have a sliding scale for fees?
Do you offer video visits?
What is your philosophy for patient care?
Image #1: Professional Headshot / Profile Picture
(Required)
Max. file size: 2 MB.
Profile Image #2: Profession Image
(Required)
Max. file size: 2 MB.
Ideas: In your office, outside your facility, with your staff....
Profile Image #3: Leisure/Family
(Required)
Max. file size: 2 MB.
Profile Image #4: Leisure/Family
(Required)
Max. file size: 2 MB.
Profile Image #5: Community Engagement Image
(Required)
Max. file size: 2 MB.
Ideas: Leadership, Volunteer, Organizations
Upload Your CV
(Required)
Max. file size: 2 MB.
Ideas: Leadership, Volunteer, Organizations
Personal quote, statement, or motto
Personal info
Please type in your NPI number
(Required)
I acknowledge that the publishers of the directory will use my NPI number to do a basic screening to ensure that the credentials and my profile that I provided are accurate.
Have you ever had your medical license revoked or suspended (This information will not be displayed in the directory.)
(Required)
Yes
No
Please explain the details of the revocation or suspension
(Required)
Have you ever been convicted of a felony? (This information will not be displayed in the directory.)
(Required)
Yes
No
Personal/Preferred Gender Pronouns (PGP)
(Required)
Have you ever been convicted of a felony? (This information will not be displayed in the directory.)
(Required)
He/Him/His
She/Her/Hers
They/Them/Theirs
Other PGP
Cell Phone Number
(Required)
WILL NOT BE MADE PUBLIC
Personal Email
(Required)
WILL NOT BE MADE PUBLIC
Bio
(Required)
Opportunities
Are you willing to be a presenter in a series of brief medical educational videos that we are creating
(Required)
Yes
No
Are you willing to have your image and story featured on digital flash cards of Black Health professionals that we are creating
(Required)
Yes
No
Are you willing to mentor underrepresented Individuals from the following groups? (Check all that apply)
Current Psychology Graduate Students
Psychology Residents
Psychologists Early in Their Careers
Are you willing to be listed on our speaker's panel of subject matter experts? If so, what is your specific area of expertise?
(Required)
