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Menu
Home
About
Letter From Our Founder
Leadership Team
Contact Us
Blog
Wellness Pods
Resource Guide
Programs & Services
African American Cultural Competency Training
Mental Wellness Support Program
Prince George’s County Public School Partnership
Senior’s Mental Wellness Client Survey
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
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**
Please enable JavaScript in your browser to complete this form.
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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:
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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.
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Please Name the School Your Child Attends
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Parent/Guardian's Name
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First
Last
Parent/Guardian's Email Address
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Parent/Guardian's Telephone/Cellphone Number
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Phone Type
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Home Phone
Cellphone
Work Phone
Child's Name
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First
Last
Child's Self-Identified Gender
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Child's Date of Birth
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Child's Prince George's County School Email
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Child's Current Residence
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Address Line 1
Address Line 2
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Alabama
Alaska
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Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Zip Code
Please Name the School You Attend
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Name:
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First
Last
Self Identified Gender:
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Your Date of Birth
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Prince George's County School Email:
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Phone Number:
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Phone Type:
Home Phone
Cellphone
Work Phone
Address:
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Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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How did you find out about us?
Social Media (Facebook, Instagram, Twitter, etc.)
Radio
Workshop/Hangout
School Email
Recommendation from Counselor
Recommendation from friend
Other
Other:
Does the child attend any school programs/extra-curriculars (ie. Sports, Arts, etc.)?
Student's Grade Level
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Does your child have a 504 or IEP?
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Yes
No
Please select a Provider
*
---
Barbara Brown of CapitolHill Consortium for Counseling & Consultation, LLC (CCCC)
Areas of Concern
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What are some strengths that you have?
What are some strengths that your child has?
Is your child a danger to themselves or others?
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Are you a danger to yourself or others?
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Currently, do you have medical insurance?
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Yes
No
Has your child ever received Mental Health services?
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Yes
No
Have you ever received Mental Health services?
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Yes
No
When was your child 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
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
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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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