Mental Health Provider Directory Form

Dear Mental Health Providers:

As you may know, the Asian American population in Illinois is rapidly growing and becoming more diverse, however, at least 79% of Asians in Chicago are linguistically isolated (US Census 2000), indicating that no household member over age 14 speaks English proficiently. Unfortunately, the lack of linguistically and culturally appropriate services prevents many immigrant families from accessing mental health care, despite the growing prevalence of mental health conditions in our communities.

To address this need, the Asian Health Coalition of Illinois (AHCI) and the Asian American Suicide Prevention Initiative (AASPI) have been compiling a directory of individuals who can provide culturally and linguistically appropriate mental health services to APIAs in Illinois. This directory will be made available to the public as a free community resource.

We hope you will take five minutes to help us in this endeavor by completing our Online Directory Submission Form and spreading the word about this resource to other providers.

Thank you very much for your assistance!

First Name *

Last Name *

Degree(s) *

License Type *

Gender *

Affiliated Agency

Main Office Address *

Main Office Address 2

City *

State *

Zip Code *

Phone *

Email *

Agency Website

Types of services provided: (Check all that apply) *: Individual Therapy Couple & Family Therapy Group Therapy

My office accepts the following forms of payment: (Check all that apply) *: Medicaid Medicare Private Insurance Self Pay Sliding Scale

I speak the following Asian/Pacific Islander languages and/or dialects fluently enough to provide services: (Check all that apply): Chamorro Chinese (Cantonese) Chinese (Mandarin) Chinese (Other)
Gujarati Hindi Hmong Indonesian
Japanese Khmer (Cambodian) Korean Laotian
Samoan Tagalog Thai Vietnamese

Trained interpreters are available for clinician visits at my office in the following Asian/Pacific Islander languages and/or dialects: (Check all that apply): Chamorro Chinese (Cantonese) Chinese (Mandarin) Chinese (Other)
Gujarati Hindi Hmong Indonesian
Japanese Khmer (Cambodian) Korean Laotian
Samoan Tagalog Thai Vietnamese

For languages that I do not personally speak, I/my office provides interpretation assistance to my clients though: (Check all that apply) *: Staff Interpreters
Contractual Interpreter Services (please specify which agency you use)
Clarification for other survey items**

** Note: if there are additional services or languages spoken that are NOT included in the survey which you provide or speak, please indicate these additions in the "Clarification for other survey items" check box towards the bottom. Thank you.