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Home
About
Causes
Donate
Let’s Talk! Resource Guide
Ask for Help NOW!
Programs and Services
The Unspoken Curriculum
Mental Wellness Support Program (Free Therapy)
Free Therapy Application
Client Quality of Service Survey
Provider Registration (PSAA)
Provider Service Completion Survey
Mental Health College Scholarship Fund
Professional Development
African American Cultural Competency Training
Contact Us
Texas and New York Mental Wellness
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Texas and New York Mental Wellness
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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. This time-limited opportunity is primarily for those experiencing stress or anxiety related to the pandemic OR those impacted directly or indirectly as a result of the injustice and maltreatment observed in the last 30 days.
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Email Address
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Date of Birth
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Date of birth of person receiving services.
Self-Identified Gender
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Please select your pronouns
*
She/Her/Hers
He/His/His
They/Them/Their
Xe/Xem/Xyr
Other
Please provide your preferred pronouns
Ethnicity
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Black or African-American
American Indian or Alaska Native
Latino or Hispanic
Asian
White or Caucasian
Other
Other:
Address
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Address Line 1
Address Line 2
City
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State
Zip Code
Telephone / Cellphone Number
*
Phone Type
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Home Phone
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Please Select a Provider IN YOUR STATE
*
Please Choose a Provider in Your State
NY - Miss Racquel Reid of Inklusive Therapy, Racquel Reid (LCSW)
NY - Mrs. Kamilah Matthew of Kamilah Matthew, Psychotherapist
NY - Miss Kellee Barrett of Kellee Barrett, LCSW - KB's Lighthouse Counseling Services
NY - Miss Keisha Cox of Keisha Cox, LCSW
NY - Ms. Candice Jarvis of CHAT&Change Counseling Services
NY - Dr. Alicia Delgado-Gavin of Dr. Alicia Delgado-Gavin, Psy.D, Tears Behind the Smile, LLC
NY - Mrs. Cheryl Mchunguzi of Metamorphosis, LMSW P.C. Cheryl Mchunguzi ,LMSW RMT
NY - Miss Rachel Johnson of Rachel Johnson, Half Hood Half Holistic LLC
NY - Mrs. Shameka Collins of Collins & Collins Clinical Services; Shameka Collins
NY - Dr. Seleena Smith of Dr. Seleena Smith—REAL Liberation Coaching & Consultation Services
NY - Miss Racquel Reid of Inklusive Therapy, Racquel Reid (LCSW)
TX - Miss Kamilah Thomas of Kamilah Thomas
TX - Ms. Kimberly Parker of Kimberly Ann Parker, Revive to Thrive Wellness, PLLC
TX - Miss Glenda Demas of Pearls Of Change Wellness
TX - Mrs. Chikeitha Owens of Abundance of Hope Counseling Service - Chikeitha Owens M.A LPC
TX - Mrs. Deitra Baker of Deitra Baker, LMFT
TX - Miss Amber Boyd of Amber Boyd, LMFT-Healing Through Authenticity
TX - Miss Janee Henderson of Janee V. Henderson, M.Ed., LPC *MO
TX - Miss Shawnnell Batiste of Shawnnell Batiste, LPC *TX
TX - Miss Rashan Carter of Rashan Carter, LCSW, Passion & Purpose Fulfilled
TX - Dr. Mel McGee of Covington-McGee Christian Counseling
TX - Mrs. Valerie Kuykendall-Rogers of Ascent Psychotherapy Center
TX - Mrs. Shameka Collins of Collins & Collins Clinical Services; Shameka Collins
TX - Miss Brittany Woodley of Brittany Woodley, The Empowering Space
TX - Mrs. Omolola Taiwo of Omolola Taiwo, NCC, LPC
TX - Miss Kindall Tyson of Aspire Counseling & Wellness Center, PLLC
TX - Miss Ebony Bailey of Ebony Bailey of Life Balance Therapy, LLC
TX - Mrs. Krista Woods of Krista Woods, M.S.W., LCSW
TX - Dr. Seleena Smith of Dr. Seleena Smith—REAL Liberation Coaching & Consultation Services
Do you have internet access and a private space for the virtual sessions?
*
Yes
No
Currently, do you have medical insurance?
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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.
*
Worry about completing your senior year, graduation or passing to the next grade (High School)
Worry about online classes, grades or receiving degree (College/Graduate)
Concerned about elder family members, friends or those with compromised immune systems
Feeling a loss of community
Lack of supplies or resources i.e food or housing
Employment and financial instability
Change in self-care activities while at home
Increase in alcohol intake/substances
Feeling silenced or injustice (marginalized or suffering in silence)
Feeling anxious due to current racial injustices towards people of color
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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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