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Mental Wellness Support Application 2024 – Jackson, MS
Mental Wellness Support Program Application 2024 - Jackson, MS
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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Disclaimer
If you are having thoughts of harming yourself or others, please call 911 or report to your local hospital immediately.
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Self-Identified Gender
*
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 ---
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Telephone / Cellphone Number
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Phone Type
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Home Phone
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Next
Please Choose a Provider in YOUR STATE
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Mississippi: Dr. Seleena Smith|REAL Liberation Coaching & Consultation Services
Mississippi: Pieces of Me Behavioral Health, LLC
Dr. Jerrilyn Dixson, LPC, RPT-S, BC-TMH|Progressive Therapy, LLC
What is your current employment status?
*
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
*
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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