NBJC Mental Wellness Support Program 2024

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.

Name

First

Last

Email Address

Email

Confirm Email

Date of Birth

Self-Identified Gender

Address

Address Line 1

Address Line 2

City

State

Zip Code

Telephone / Cellphone Number

Phone Type

Home Phone
Cellphone
Work Phone

Please Select a Provider IN YOUR STATE

Ethnicity

Do you have internet access and a private space for the virtual sessions?

Yes
No

Currently, do you have medical insurance?

Yes
No

Have you ever received Mental Health services?

Yes
No

Please select your primary concern.

Worry about online classes, grades or receiving degree (College/Graduate)
Feeling a sense of hopelessness
Feeling a loss of community
Lack of supplies or resources (i.e food or housing)
Employment and financial instability
Increase in alcohol intake/substances
Feeling silenced or injustice (marginalized or suffering in silence)
Feeling anxious due to injustices towards people of color
Loss of a loved one

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.

Disclaimer

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