Prince George's County Public School Partnership - The Boris Lawrence Henson Foundation

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Prince George's County Schools Mental Health Partnership

During this challenging time, the Boris L. Henson Foundation recognizes that affording the cost to seek services can be a barrier. The Prince George's County Schools Mental Health Partnership, was developed to cover the cost of therapy services by licensed clinicians in our network for up to five (5) sessions. This short-term opportunity will assist those in the Prince George's County School District. If you are enrolling multiple children, a separate application is required for each child. ** A representative from BLHF will contact the parents/guardians of the students to confirm the information given before the student receives services**

- Step 1 of 4

Disclaimer

If you have 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 due to injustice and maltreatment observed in the last 30 days.

Who is applying: *

Parent/Legal Guardian (For Students Under 18 Years Old)
Student (For Students 18+)

The Prince George's County Schools Mental Health Partnership is for students only. If you are younger than 18 years old, a parent/legal guardian must fill out this form.

Please Name the School Your Child Attends *

Parent/Guardian's Name *

First

Last

Parent/Guardian's Email Address *

Parent/Guardian's Telephone/Cellphone Number *

Phone Type *

Home Phone
Cellphone
Work Phone

Child's Name *

First

Last

Child's Self-Identified Gender *

Child's Date of Birth *//

Child's Prince George's County School Email *

Child's Current Residence *

Address Line 1

Address Line 2

City

State

Zip Code

Please Name the School You Attend *

Name: *

First

Last

Self Identified Gender: *

Your Date of Birth *//

Prince George's County School Email: *

Phone Number: *

Phone Type:

Home Phone
Cellphone
Work Phone

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

How did you find out about us?

Other:

Does the child attend any school programs/extra-curriculars (ie. Sports, Arts, etc.)?

Student's Grade Level *

Does your child have a 504 or IEP? *

Yes
No

Please select a Provider *

Areas of Concern *

What are some strengths that you have?

What are some strengths that your child has?

Is your child a danger to themselves or others? *

Are you a danger to yourself or others? *

Currently, do you have medical insurance? *

Yes
No

Has your child ever received Mental Health services? *

Yes
No

Have you ever received Mental Health services? *

Yes
No

When was your child last seen? *

When were you last seen? *

Informed Consent and Participation Agreement - ALL acknowledgments MUST BE CHECKED to process your registration *

By submitting a Prince George's County Schools Mental Health Partnership registration, I acknowledge that a BLHF representative will contact me regarding the information provided; it is my duty to confirm the information I have given or risk registration closure.
I authorize sharing my registration and its contents (referral) with my chosen provider and company by submitting a Prince George's County Schools Mental Health Partnership registration. Questions regarding your HIPAA patient rights, responsibilities, and release of information must be sent to your treating provider if desired.
I acknowledge and permit 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 the campaign does not cover service fees for notable exceptions, insurance copays, no-shows, and referrals to alternate providers agreed upon between my provider and me.
I will submit the mandated Quality of Service Survey online after EVERY visit.

To process your application check all boxes for completion.

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BLHF is a registered 501(C)3 nonprofit EIN 82-3814846

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