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The Boris Lawrence Henson Foundation
Break the Silence Break the Cycle
Home
About
Letter From Our Founder
Leadership Team
Contact Us
Blog
Resource Guide
Programs & Services
African American Cultural Competency Training
Mental Wellness Support Program
Women’s Mental Wellness Client Survey
Release Trauma Client Survey
150 Black Men Client Quality of Service Survey
Provider Service Completion Survey
Provider Service Availability and Agreement
The Unspoken Curriculum
Scholarship Fund
Ways to Give
Give Monthly – Make Joy Revolutionary
Give Change – Connect a card to round-up your purchases to the next dollar and donate your change!
Donate
Search:
Home
About
Letter From Our Founder
Leadership Team
Contact Us
Blog
Resource Guide
Programs & Services
African American Cultural Competency Training
Mental Wellness Support Program
Women’s Mental Wellness Client Survey
Release Trauma Client Survey
150 Black Men Client Quality of Service Survey
Provider Service Completion Survey
Provider Service Availability and Agreement
The Unspoken Curriculum
Scholarship Fund
Ways to Give
Give Monthly – Make Joy Revolutionary
Give Change – Connect a card to round-up your purchases to the next dollar and donate your change!
Donate
Mental Wellness Support for College Invoice Portal
This is the only authorized source to submit an invoice for the Partnered Colleges.
Please enable JavaScript in your browser to complete this form.
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Step
1
of 3
Please select Client's School
*
Howard University, Chadwick Boseman School of Fine Arts
Please select your Company or Organization
*
Please select your business
Petrina L. Williams LICSW, LCSW-C Miracles In Motion Therapy and Consulting LLC
Capitol Hill Consortium for Counseling & Consultation
Montrella Cowan, CEO of Affinity Health Affairs, LLC, Licensed Therapist, Life Coach, Author, and Speaker
Address
*
Address Line 1
Address Line 2
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Email
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Phone
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Service Provider
Provider Name
*
First
Last
Client
Client Name
*
First
Last
Client Number
*
Client Session Number
*
1st session
2nd session
3rd session
4th session
5th session
Visit Date / Time
*
Date
Time
Visit CPT Code
*
90836: Forty-five minutes of individual psychotherapy performed with an E/M service
90837: Sixty minutes of individual psychotherapy
90838: Sixty minutes of individual psychotherapy performed with an E/M service
90847: Family psychotherapy with the patient present
90846: Family psychotherapy without the patient present
Other
Other CPT Code
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Billable Charge
*
Universal Flat Rate - $150.00
I accept the universal flat rate per session.
Payment Choice
*
Direct Deposit (ACH Transfer) - 14 business day processing
Name on Account
*
Routing Number
*
Account Number
*
The person submitting this invoice is the owner or an authorized agent.
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Owner / Provider
Authorized Agent
Authorized Agent's Name and Title
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