Skip to content
(213) 222-6327
info@borislhensonfoundation.org
Monday – Friday 10 AM – 8 PM
Facebook page opens in new window
Twitter page opens in new window
Instagram page opens in new window
YouTube page opens in new window
The Boris Lawrence Henson Foundation
Break the Silence Break the Cycle
Home
About
Letter From Our Founder
Leadership Team
Contact Us
Blog
The JOY Shop
Let’s Talk! Resource Guide
Programs and Services
African American Cultural Competency Training
Mental Wellness Support Program
Release Trauma Client Survey
150 Black Men Mental Support Program
150 Black Men Client Quality of Service Survey
Provider Service Completion Survey
Provider Service Availability and Agreement
The Unspoken Curriculum
Scholarship Fund
Donate
Search:
Home
About
Letter From Our Founder
Leadership Team
Contact Us
Blog
The JOY Shop
Let’s Talk! Resource Guide
Programs and Services
African American Cultural Competency Training
Mental Wellness Support Program
Release Trauma Client Survey
150 Black Men Mental Support Program
150 Black Men Client Quality of Service Survey
Provider Service Completion Survey
Provider Service Availability and Agreement
The Unspoken Curriculum
Scholarship Fund
Donate
Prince George County Mental Wellness Client Survey
Please enable JavaScript in your browser to complete this form.
Multiple Choice
Kenmore Middle School
Benjamin Stoddert Middle School
Buck Lodge Middle School
High Point High School
Friendly High School
Suitland High School
Sitar Arts Center
Name
*
First
Last
Client ID
*
This is NOT your SSN. Refer to the registration sign-up email for your client number, please use the full ID numbers and letters.
Email Address
*
Your Therapist / Mental Health Provider
*
-Please Choose Your Provider-
Keisha Lashon Mack of The MECCA Group, LLC
Cherinna Hardeman of Trihearts and Trihearts Counseling
Barbara Brown of CapitolHill Consortium for Counseling & Consultation, LLC (CCCC)
Cara Alexander of Embrace Life, LLC
Dyverynce Vaughan of Feeling Moody LLC
Dr. Leeshe Grimes of Dr. Leeshe Grimes Elevated Minds
Montrella Cowan of Montrella Cowan, MSW, LICSW
Petrina Williams of Petrina L. Williams LICSW, LCSW-C Miracles In Motion Therapy and Consulting LLC
Please use the drop-down menu to choose your Provider.
Session Date / Time
*
Date
Time
Your Experience
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Overall, how would you rate your experience with us?
How satisfied were you with
*
Unsatisfied
Neutral
Very Satisfied
Your Treatment
Unsatisfied
Your Treatment Unsatisfied
Neutral
Your Treatment Neutral
Very Satisfied
Your Treatment Very Satisfied
Timely Session Scheduling
Unsatisfied
Timely Session Scheduling Unsatisfied
Neutral
Timely Session Scheduling Neutral
Very Satisfied
Timely Session Scheduling Very Satisfied
Technology
Unsatisfied
Technology Unsatisfied
Neutral
Technology Neutral
Very Satisfied
Technology Very Satisfied
How likely are you to
*
Unlikely
Neutral
Likely
Schedule a new appointment
Unlikely
Schedule a new appointment Unlikely
Neutral
Schedule a new appointment Neutral
Likely
Schedule a new appointment Likely
Recommend this provider to others
Unlikely
Recommend this provider to others Unlikely
Neutral
Recommend this provider to others Neutral
Likely
Recommend this provider to others Likely
Recommend BLHF to others
Unlikely
Recommend BLHF to others Unlikely
Neutral
Recommend BLHF to others Neutral
Likely
Recommend BLHF to others Likely
Have you scheduled a follow-up visit with this provider?
*
Yes
No
If not, do you plan to schedule a follow-up visit with this provider?
*
Yes
No
How was your experience?
*
We're sorry you if did not have a good experience. Please let us know how we can do better.
Comment
Submit
Call Now Button