Thank you for your interest in joining the Brown Sugar Clinicians — a community of culturally responsive, licensed mental health professionals committed to closing the gap in behavioral health access for communities of color. Please complete this interest form in full so we can learn more about your background, clinical expertise, and how you envision contributing to our collective mission.

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1. Please provide your basic contact information:

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2. What is your license type and credential information?

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3. NPI Number

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4. Are you currently accepting new clients?

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5. Which therapeutic modalities do you use in your clinical practice? Check all that apply

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6. What is your clinical specialty or area of focus?

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7. Which age groups do you prefer to serve? Check all that apply.

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8. Do you have experience working with any of the following populations? Check all that apply.

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9. Why are you interested in joining the Brown Sugar Clinicians?

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10. How are you willing to contribute to the Brown Sugar Clinicians

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11. What Skills, Resource or connections can you bring to the group?

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12. BSC Branded Apparel Polo Shirt Size ($35 Cost)

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13. How did you hear about Brown Sugar Clinicians?

By submitting this form, I under the membership requirements listed below. I also affirm that all information provided is accurate and that I hold active licensure in the state(s) listed above, or that I am an intern actively pursuing professional licensure. I understand that submission of this survey does not guarantee membership and that a representative from Brown Sugar Clinicians may contact me for additional information.

Membership Requirements:
1. No membership fees at this time- accessible to all clinicians
2. Quarterly Zoom meetings - professional networking and peer support
3. Three community events annually - engage in outreach and education
4. Committee participation - join at least one BSC committee
5. BSC embroidered polo shirt (approx. $35) - professional attire for public events

We look forward to connecting with you and welcoming you to our community of passionate clinicians.
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