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Founded by Taraji P. Henson, The Boris Lawrence Henson Foundation’s mission is to eradicate the stigma around mental health, in hopes that people will seek out the help they need. In response to these extraordinary times of social injustice and unrest, over the years, BLHF developed an emergency fund to provide free mental health care for individuals affected by vicarious trauma in the African American community. BLHF has partnered with DCJS (Division of Criminal and Justice Services) to provide staff members access to free Individual and Group Therapy Sessions. Complete the application below to connect with a Mental Health Professional. To learn more about the Mental Health Professionals, you can search them in our directory, Let’s Talk! Resource Guide. If you need assistance completing the application from a BLHF Representative please call 1(213) 493-5005 or email us at mwspinquiry@borislhensonfoundation.org
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Disclaimer
If you are having thoughts of harming yourself or others, please call 911 or report to your local hospital immediately.
SNUG Site Location:
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Niagara Falls
Buffalo
Rochester
Syracuse
Utica
Albany
Troy
Poughkeepsie
Newburgh
Mount Vernon
Yonkers
Bronx
Hempstead
Wyandanch
Name
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First
Last
Email Address
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Date of Birth
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Self-Identified Gender
*
Ethnicity
*
Black or African-American
American Indian or Alaska Native
Latino or Hispanic
Asian
White or Caucasian
Other
If Other:
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
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
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Telephone / Cellphone Number
*
Phone Type
*
Home Phone
Cellphone
Work Phone
Next
Please Select a Provider:
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Kellee Barrett, LCSW | KB's Lighthouse Counseling Services| Kellee Barrett
Keisha Cox | Keisha Cox, LCSW
Candice Jarvis | CHAT & Change Counseling Services
Cheryl Mchunguzi ,LMSW RMT | Metamorphosis, LMSW P.C. | Cheryl Mchunguzi
Isaac Collins | Collins & Collins Counseling Services
Giorgio Durham | Giorgio Durham, LPC & Life Coach
Rachel Johnson | Half Hood Half Holistic LLC, Rachel Johnson
Racquel Reid | Dynamic and inclusive Therapy Services
Seleena Smith | Real Liberation Coaching and Consulting Services
Do you have internet access and a private space for the virtual sessions?
*
Yes
No
Currently, do you have medical insurance?
*
Yes
No
Have you ever received Mental Health services?
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Yes
No
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
Please select your primary concern.
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Trauma
Grief and Loss
Depression
Anxiety
Work-Life Balance
Dealing with Stress
Eating Disorders
Anger Management
Addiction/Substance Abuse
Family Challenges
Emotional Wellness
Domestic Abuse
Phobias
Self-Care
Weight and Body Issues
Other
Are you also interested in participating in Group Therapy Sessions?
*
Yes
No
How did you learn about us?
Informed Consent and Participation Agreement - ALL acknowledgments MUST BE CHECKED to process your registration
*
I acknowledge by submitting a Mental Wellness Support Program registration, I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities and/or release of information must be sent to your treating provider, if desired.
I acknowledge and give permission for any and 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 service fees for special exceptions, insurance copays, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign.
I will ensure the mandated Quality of Service Survey is submitted online after EVERY visit.
All boxes must be checked to process your registration.
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