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Prince George’s County Public School Partnership
Prince George's County Schools Mental Health Partnership
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. In response to the unique challenges the Prince George's County community faces during these unprecedented times, BLHF recognizes the critical need for mental health services and has taken a proactive approach by implementing a verification process for intake. This verification process safeguards resources and ensures that individuals who genuinely need services receive them. If you are enrolling multiple children, a separate application is required for each child. ** Verification of a PGCPS association will be needed before services are received. Also a representative from BLHF will contact the parents/guardians of students who are under 14 years old to confirm the information given before the student receives services**
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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, anxiety, trauma OR those impacted directly or indirectly due to injustice and maltreatment observed in the last 30 days.
Who is applying:
*
Staff
Parent/Legal Guardian (Applying for Themselves)
Parent/Legal Guardian (Applying for Students Under 14 Years Old)
Student (For Students 14 and Older)
Students ages 14+ CAN register without parental consent.
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Please Name the School Your Child Attends
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Your Name
*
First
Last
Your Email Address
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Your 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
*
Child's Current Residence
*
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
Please Name Your School
*
Your Name:
*
First
Last
Your Self Identified Gender:
*
Your Date of Birth
*
MM
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2
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5
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8
9
10
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DD
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5
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15
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20
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28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1998
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1981
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1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
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1921
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Your Email Address
*
NOT a Prince George's County Email
Your Phone Number:
*
Phone Type:
Home Phone
Cellphone
Work Phone
Your Address:
*
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
*
Does your child have a 504 or IEP?
*
Yes
No
Please select a Provider
*
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CapitolHill Consortium for Counseling & Consultation, LLC (CCCC)
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?
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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?
*
Yes
No
Have you ever received Mental Health services?
*
Yes
No
When was your child last seen?
*
< 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?
*
< 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.
Please Submit Your Prince George's County Email For Verification
*
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