Provider Submission

Do you have a great practitioner that we need to know about? Are you a provider that we've missed? Fill out this form and we'll work to get your info added! Items marked with * are required to be filled in.

Submitter Info

In the event that we should have clarifying questions, please provide us your contact info.

This info will not be shared.

Provider Info

Please give as much information as possible.

While we do not currently utilize all of these options, We intend to expand our listings in the future.

(or contact person)
Provider Address

Services Offered



Technical issues with this form? Send email to or text 859.448.LGBT (5428).