Thank you for your interest in joining Jax Therapy Network.

Please Note:

  • Listing Title Field:  Enter your First and Last Name, followed by your license abbreviation.
    e.g. Joe Smith, LMHC or Betty Jones, PhD
  • Address/Listing Locations:
    • Users WITH physical locations in Florida or Georgia: use “Listing Locations” section at bottom of the form.
    • Users with physical location other than Florida or Georgia: Use “Address (via Telehealth)” in “Contact Information” section.

Returning user? Please Log in or register in this submission form.

Login information will be sent to your email after submission

Expand All | Collapse All

LIMIT=3

Limit = 500 Characters
A brief introduction about yourself and/or your practice. Think - "Mission Statement".
Please note the following:

  • Page reloads due to errors or omission of required form fields may result in lost text in this or other text fields. Users are recommended to use a text editor, or a character counting tool to set text for easy retrieval in case of lost text on form/page reload.
  • This form does not provide an inline character counter. For convenience, you can use a character counting tool

(e.g. Individual and Couples Counseling)

LIMIT = 6
"Other Practice Areas" limited to a maximum of six.
Profiles with more than six items selected will be held for moderation until corrected by profile owner.

Describe your education and training background

This field only for locations outside of Florida or Georgia.
Enter as a single line as follows: 123 Street Name, Suite #2, City, State, Zip
For locations in Florida or Georgia, leave blank and use "Listing Location" section at bottom.

Select one option only.

Briefly describe each group therapy available.

Monday   -  
Tuesday   -  
Wednesday   -  
Thursday   -  
Friday   -  
Saturday   -  
Sunday   -  

Group therapy session time,

Limit = 500 Characters
In practice since…; Memberships, etc.
Please note the following:

  • Page reloads due to errors or omission of required form fields may result in lost text in this or other text fields. Users are recommended to use a text editor, or a character counting tool to set text for easy retrieval in case of lost text on form/page reload.
  • This form does not provide an inline character counter. For convenience, you can use a character counting tool

Content fields may be dependent on selected categories

Attach images

Drop here

Attach videos

This field for members with a physical address in either Florida or Georgia only.
If your office is located outside of Florida or Georgia, leave this section blank and use address field "Address (via Telehealth)" in "Contact Information" section above.

  • Enter street and suite numbers on Address line 1
  • Enter city and state on Address line 2 as shown in this example:
    address fields sample