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MWSP Jacksonville, FL Application 2024
MWSP Jacksonville, FL 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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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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If Other:
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City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Florida
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Telephone / Cellphone Number
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Next
Please Choose a Provider in YOUR STATE
*
FL - Taliah Williams-Hunter, Emerge Counseling Services
FL - Jason Prendergast, Edify Counseling Group LLC
FL - LaMora Pace, LCSW, CAP / The Healing Crest Counseling Services, LLC
FL - Isaac Collins
FL - Mellisa Gooden, LMFT, LMHC, MA | A Good Place For Help
FL - Renee Manneh, LCSW
FL - Omolola Taiwo, NCC, LPC
FL - Dr. Cortnie S. Baity, LMFT | Onward and Upward Psychotherapy & Consulting Services, LLC
FL - Lakisha Foxworth, LMFT
FL - Monique Pierre-Louis, LPC|En Touch Counseling & Consulting, LLC
Choice 717
Choice 718
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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