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Bennett College Free Therapy Application
Founded by Taraji P. Henson, The Boris Lawrence Henson Foundation’s mission is to eradicate the stigma around mental health in the Black community, in hopes that people will seek out the help they need. This program is to help female identifying students, if you are male or male identifying please contact the School Counseling Center for support.
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Disclaimer
If you are having thoughts of harming yourself or others, please call 911 or report to your local hospital immediately.
Name
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First
Last
Student ID
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Your Bennett Student ID is needed
Email Address
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Date of Birth
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Self-Identified Gender
*
This program is to help female identifying students, if you are male identifying please contact the School Counseling Center for support.
Please select your pronouns
She/Her/Hers
He/His/His
They/Them/Their
Xe/Xem/Xyr
Other
If Other:
Ethnicity
*
Black or African-American
American Indian or Alaska Native
Latino or Hispanic
Asian
White or Caucasian
Other
If Other:
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Telephone / Cellphone Number
*
Phone Type
*
Home Phone
Cellphone
Work Phone
Next
Please Select a Provider
*
--Please Choose a Provider--
Myracle Clay-Bennett, Ellie Mental Health
Cydnia Young, Dope Soul Wellness
Keturah Davis, OIC Counseling and Wellness
Quashawn Pernell, OIC Counseling and Wellness
Cynia Black, OIC Counseling and Wellness
Roxie Sutton, Maximum Potential Counseling
Ella Smith, Reinvent Therapeutic Services
What year of college are you in?
*
Auditing
Freshmen
Sophomore
Junior
Senior
Graduate (M.A, M.S, Ph.D, etc)
Other
Currently, do you have medical insurance?
*
Yes
No
Have you ever received Mental Health services?
*
Yes
No
When were you last seen?
*
< Less than 30 days
Between 30 days and 6 months
Between 6 months and 1 year
1 year and 5 years
> Greater than 5 years
Please select your primary concern.
*
Feeling of hopelessness
Feeling a loss of community
Loss of a loved one
Lack of supplies or resources i.e food or housing
Employment and financial instability
Change in self-care activities while at home
Increase in alcohol intake/substances
Feeling silenced or injustice (marginalized or suffering in silence)
Feeling anxious due to current racial injustices towards people of color
Other
Informed Consent and Participation Agreement - ALL acknowledgments MUST BE CHECKED to process your registration
*
I acknowledge by submitting a Mental Wellness Support Program registration, I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities and/or release of information must be sent to your treating provider, if desired.
I acknowledge and give permission for any and all information associated with my registration to be used by the Boris L Henson Foundation strictly for billing, statistics and quality assurance.
I acknowledge that service fees for special exceptions, insurance copays, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign.
I will ensure the mandated Quality of Service Survey is submitted online after EVERY visit.
All boxes must be checked to process your registration.
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