Friendly High School Mental Wellness Partnership - The Boris Lawrence Henson Foundation

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Friendly High School Mental Wellness Project 2022 is Open

The Boris L. Henson Foundation is proud to work with Friendly High School to help increase access to competent and quality mental health support for its students and staff. The Mental Wellness Partnership was developed to cover the cost of virtual or teletherapy services by licensed clinicians in our network for up to five (5) sessions. This short-term opportunity is offered to those experiencing a life-changing event or those who simply need support.

Services are Now Offered:

Individual virtual sessions
- Up to five (5), short term sessions as clinically indicated by the provider
Does not retroactively cover services received before approval or for out of network providers

Application Process:

Step 1 – Search the BLHF Resource Guide and filter by state.

Step 2 – Select your preferred provider.

Step 3 – Submit your participant application.

- Step 1 of 4

Disclaimer

If you are having thoughts of harming yourself or others, please call 911 or report to your local hospital immediately. This time-limited opportunity is primarily for those experiencing stress or anxiety related to the pandemic OR those impacted directly or indirectly as a result of the injustice and maltreatment observed in the last 30 days.

Who is applying: *

Parent/Legal Guardian
Faculty
Family Member

Family members of students attending Prince George County Public Schools are welcome to apply to our other great programs and services.

The therapy is for: *

Yourself
Child

Parent/Guardian's Name *

First

Last

Parent/Guardian's Email Address *

Parent/Guardian's Telephone/Cellphone Number *

Phone Type *

Home Phone
Cellphone
Work Phone

Child's Name *

First

Last

Child's Self-Identified Gender *

Child's Date of Birth *//

Child's Current Residence *

Address Line 1

Address Line 2

City

State

Zip Code

Name: *

First

Last

Self Identified Gender: *

Email: *

Phone Number: *

Phone Type:

Home Phone
Cellphone
Work Phone

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

School Representative or Referring Source

School Program (ie, STEM, Autism, CTE, etc.)

Child's Grade Level *

Does your child have a 504 or IEP? *

Yes
No

Please select a Provider *

Areas of Concern *

What are some strengths that you have?

What are some strengths that you and/or the child have?

Are you and/or the child a danger to yourselves or others? *

Are you a danger to yourself or others? *

Currently, do you have medical insurance? *

Yes
No

Have you or the child ever received Mental Health services? *

Yes
No

Have you ever received Mental Health services? *

Yes
No

When were you or the child last seen? *

When were you last seen? *

Informed Consent and Participation Agreement - ALL acknowledgments MUST BE CHECKED to process your registration *

I acknowledge by submitting a Prince George County Public School Mental Alliance Project 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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© 2021 Boris Lawrence Henson Foundation
BLHF is a registered 501(C)3 nonprofit EIN 82-3814846

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