New Provider Registration

Fill in the form below to create an account within the Directory. Once your account has been created, you will be able to login the directory, provide your provider information and submit it for inclusion in the directory. Once your information is in the directory, this account will continue to allow you to log in and keep your information up to date.

Fields marked with a red are REQUIRED to submit this form.

First Name

Last Name

Title

Email Address

Phone

Username

Login Name must be at least 4 characters, and contain only letters, numbers, underscore (_), dash (-), ampersand (&) or period (.). Check if it passes the rules?

Password

Your Password must be at least 8 characters, and contain three of the following: Uppercase, lowercase, numbers and/or non-alphabetic characters. Check if it passes the rules?

Re-enter Password

Florida's Maternal Behavioral Health and Social Services Resource Directory

New Provider Registration

Medical or Psychiatric Emergency

Mental Health Crisis

988lifeline.org

Non-emergency

Call 1-833-TLC-MAMA (1-833-852-6262)