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Partnership Support Program Application 2024
At the Boris L. Henson Foundation, we are committed to promoting mental health and well-being, recognizing impact that the everyday can have on us. BLHF developed the Mental Support Wellness Program to provide free mental health care for individuals. The BLHF Mental Wellness Support Program covers the cost of five virtual or teletherapy sessions by licensed clinicians in our network. Please select a provider in your state.
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Please enable JavaScript in your browser to complete this form.
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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.
Partnership / Program
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JOY ZONES!
The Black Man Project (Texas)
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Self-Identified Gender
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Ethnicity
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Black or African-American
American Indian or Alaska Native
Latino or Hispanic
Asian
White or Caucasian
Other
If Other:
Address
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Address Line 1
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
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Montana
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Telephone / Cellphone Number
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Phone Type
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Home Phone
Cellphone
Work Phone
Next
Please Choose a Provider in YOUR STATE (copy)
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Maryland: Dr. Amanda Davis-Buie, PhD, LPC, LBS, NCC|Strength, Love, and Motivation, LLC
Maryland: Dr. Leeshe Grimes, LCPC|Elevated Minds
Maryland: Dr. Seleena Smith|REAL Liberation Coaching & Consultation Services
Maryland: Isaac Collins, LMSW|Collins & Collins Counseling Services
Maryland: Petrina L. Williams LICSW, LCSW-C | Miracles In Motion Therapy and Consulting LLC
Maryland: Pieces of Me Behavioral Health, LLC
Maryland: Razaria Best, LMFT|Knowledge Therapy For Thoughts, LLC
Maryland: The MECCA Group, LLC
Maryland: Thrive Counseling Teletherapy Services
Maryland: Transcend Clinical Services, Inc
Maryland: Twanna Carter, LPC | JBC Counseling & Consulting, LLC
Maryland: Asia Vianna Leak | Love Yoga Studio
Maryland: Marcia Chichester | Dr. Marcia P. Chichester, LCSW, P.L.L.C.
Please Choose a Provider in YOUR STATE
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Texas: Abe Turner, MA, LPC-A | The Weekend Therapist
Texas: Amber Boyd, LMFT | Healing Through Authenticity
Texas: Angela L. Mull | Angela L. Mull Psychotherapy Creating Beautiful Minds
Texas: Valerie Kuykendall-Rogers | Ascent Psychotherapy Center
Texas: Brittany Woodley, LCSW | The Empowering Space
Texas: Calvary Sampson | Calvary De'Rosa Counseling and Consulting
Texas: Chikeitha Owens M.A LPC | Abundance of Hope Counseling Service
Texas: Dr. Mel McGee | Covington-McGee Christian Counseling
Texas: Doreatha Page | Rooted In Hope Therapy
Texas: Deitra Baker | Deitra Baker, LMFT
Texas: Demetryas Pennegraph | Demetryas Pennegraph, MS-Mental Health Counseling- R.E.A.L. Wellness (Restoring, Educating And Leading)
Texas: Dr. Catina Miller | Mindful Wellness Reset: Relax, Release & Renew, PLLC
Texas: Dr. Diona Shelton, LCSW | New Beginnings Counseling Services
Texas: Dr. Seleena Smith | REAL Liberation Coaching & Consultation Services
Texas: Janee V. Henderson | Janee V. Henderson, M.Ed., LPC
Texas: Jason Prendergast | Edify Counseling Group LLC
Texas: Glenda Demas LPC, ACTP | Pearls of Change Wellness
Texas: Isaac Collins, LMSW | Collins & Collins Counseling Services
Texas: Kimberly Ann Parker | Kimberly Ann Parker, Revive to Thrive Wellness, PLLC
Texas: Krista Woods | Krista Woods, M.S.W., LCSW
Texas: Omolola Taiwo | Omolola Taiwo, NCC, LPC
Texas: Tanesha Graham | Pieces of Me Behavioral Health
Texas: Rashan Carter, LCSW|Passion & Purpose Fulfilled
Texas: Rayvene Whatley | Rayvene Whatley, LPC, LPC-S
Texas: Shameka Collins, LMSW | Collins & Collins Counseling Services
Texas: Shawnnell Batiste, LPC | Choosing Empowerment
Texas: Andranique Goodman | The Inner Mind Counseling & Wellness
What is your current employment status?
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Unemployed
Student (High School/College)
Employed - Part Time
Employed - Full Time
Retired
Other
Prefer Not to Answer
Do you have internet access and a private space for the virtual sessions?
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Yes
No
Currently, do you have medical insurance?
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Yes
No
Have you ever received Mental Health services?
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Yes
No
When were you last seen?
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< 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.
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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 of loneliness or isolation
Feeling silenced or injustice (marginalized or suffering in silence)
How did you learn about us?
Informed Consent and Participation Agreement - ALL acknowledgments MUST BE CHECKED to process your registration
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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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