Affiliate Information Request

Navigate Family Therapy Affiliate Info Request

Complete this short form to find out if being a Navigate Private Practice Affiliate is right for you. It takes just a few minutes and someone from out team will reach out to you quickly.

"*" indicates required fields

Your Name*

First Last

Phone

Your Email*

What state(s) are you licensed in?*

What license(s) do you hold?*

What school or training program did you attend?*

What degree did you receive?*

What are your areas of specialty?*

How many clients are you seeing per week?

1-5

5-10

10-15

15 & above

How many clients would you like to see per week?

less than 10

10-20

20-30

30 or higher

Please tell us why you would like to join the Navigate community of clinicians and why you feel you'd be a good fit:

Please tell us anything else you would like us to know about you.

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