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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
Senior Citizen Group Therapy Participation Application
The Senior Citizen Group Therapy Participant Application allows Resource Guide members to apply for BLHF's Senior Group Initiaitive. The initiative covers free in-person and virtual group therapy for adults ages 65 and older. PLEASE SUBMIT ONE APPLICATION PER GROUP!
Please enable JavaScript in your browser to complete this form.
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Step
1
of 5
Do you or your company have an ACTIVE Resource Guide Listing?
*
Yes. Please proceed.
No. A published RG listing is required
Please ensure your Resource Guide listing is published. An individual practice subscription is $12.95 per month per provider (1-5 providers). A corporate subscription is $99 per month for practices with 5 providers or greater. Indicate your company / organization name on this agreement. Non-Profits are free with verified documentation.
Next
Company or Organization (if applicable)
Title
*
Mr.
Miss
Mrs.
Dr.
Provider Name
*
First
Last
Email Address
*
Telephone Number
*
Instagram Page
We will tag support for approved groups on BLHF's Instagram page and website.
License Type
*
LPCC
LMFT
LCSW
Psychologist
CNP
MD
LMFT
Other
Other, please specify
Please list all states where you are licensed.
*
A copy of your license will be required if approved.
Please confirm your license is in good standing.
*
Yes, it is.
No, it is not. (Please do not submit)
Next
Provider's Bio
*
Please highlight relevant experience with the target age group and past experiences offering the group itself.
Do you plan to have other providers, interns, students or associates facilitate the group?
*
Yes
No
All co-facilitators must be licensed providers.
Please provide the name(s) and bio(s) of any other anticipated facilitators.
*
Next
Group Title
*
Brief Group Description
*
Group Outline or Syllabus
*
Generally breakdown the sessions over the course of the group.
Please identify target age range for the group.
*
65 -70 years old
70+ years old
Topic
*
Health Concerns
Lonliness/Isolation
Life Transitions / Adjustments
Everyday Activities
Lack of Routines/Independence
Financial Instability
Mindfulness / Meditation
General Support
How many group sessions are in the cohort?
*
Three (3)
Four (4)
Five (5)
Six (6)
Up to six (6) group sessions in a cohort.
How will the group meet?
*
Virtually
In-Person
Up to six (6) group sessions in a cohort.
Where will the group meet?
*
Church
Community Center
Other
Please provide the name of the location.
How frequently will the group meet (in days)?
Selected Value:
0
If the cohort has up to six (6) group sessions, all sessions must be completed within 2 months of approval.
Elaborate on the therapeutic approach and include a shareable link or website to any relevant evidence and research.
*
As a newly proposed group, A) Please share how you identified the need for this group in your community (include any empirical data) and B) How you will evaluate impact and quality?
*
Next
Please review and acknowledge acceptances of ALL criteria by checking the associated box.
*
I understand that the group must start within 14 - 21 days after approval. A minimum of 10 clients must be registered. As provider, I am responsible for marketing and promotion.
I certify that I have or will (1) Attend a live Provider Onboarding Training OR (2) Watched Provider Onboarding Training Video.
I agree with the expectations and duties as a mental health provider collaborating with the BLFH organization addressed in the Provider Onboarding Training.
I understand that in order to receive compensation for services, the client must complete an online Quality of Service Survey at the end of each session.
I agree that I must contact the organization if my availability changes or if there is an adverse event in the group.
I have the state mandated liability and malpractice insurance (as mandated by the state in which I practice) and I, for myself and on behalf of any practice, company, organization or entity to which I may be a part and each and any employee, officer, partner, member, staff, personnel, and/or affiliated or related individual or entity thereof, shall indemnify, defend, irrevocably release, discharge, absolve, covenant not to sue and hold the Boris Lawrence Henson Foundation (“BLHF”) (and any other relation to the organization whether individual or entity) and each and any employee, partner, member, staff, personnel and/or affiliated or related individual or entity harmless against any and all claims, liabilities and causes of action (whether third party or otherwise) of whatsoever nature arising from misrepresentation, default, misconduct, failure to perform or any other act related to this agreement and/or service provided as a part of this agreement.
I understand the relationship between myself, my company and BLHF shall at all times be that of independent contractors. No employment, partnership or joint venture relationship is formed by this referral agreement and at no time may I position myself as affiliated to BLHF, except as an independent referrer. In view of this independent relationship I shall not enter into any agreements on behalf of the BLHF, shall make no guarantees either expressed or implied on behalf of BLHF.
Type First and Last Name
*
Please enter your first and last name to acknowledge acceptance of the terms and conditions of this agreement and the signed terms of the Resource Guide Member Agreement.
Signature
Clear Signature
Single Line Text
Comment
Submit
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