CWUW Mental Health Provider Partnership

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Please complete this form if you provide mental or emotional health services in Indianapolis and would like to partner with our Connection 4 Wellness program.
Connection 4 Wellness connects women, especially Black women and other women of the Global Majority, to culturally responsive providers and contributes up to $500/year toward their care.
Please answer each question thoroughly. Completing this form isn't an assurance of referrals. All providers much be vetted for their experience, licensures, and acceptance of diverse clients. Someone from the Centers of Wellness for Urban Women will be in contact with you about your addition to this listing. Thank you!

Email *

Your Full Name

What type of provider are you? *

Licensed psychologist

Licensed psychiatrist or nurse practicioner

Licensed counselor, clinician, or therapist

Licensed clinical social worker

Certified peer specialist

Certified grief coach

Certified life coach or wellness coach

Other:

Required

Name of your practice

Address of your practice *

Phone Number

Website

Are you able to prescribe medications? *

Yes

What are your therapy types and/or modalities? *

Specialty areas *

Please list your licenses and certifications. Our partners must be licensed and/or certified in their fields. *

What is your therapeutic approach to race, gender, and other types of bias? *

Are you currently receiving new patients? *

Yes

Do you provide group support? *

Yes

Do you offer virtual or in-person sessions? *

Virtual Only

In-person Only

Both

What insurance do you accept at this time? *

For clients who may have a financial need, do you offer assistance, such as scholarships or sliding scale fees? *

Yes

If no or maybe, please explain in what other ways you could help the client receive services. (If yes, type N/A) *

What type of partnership with Connection 4 Wellness are you interested in? *

A referral only partnership: C4W will refer women to my practice. I will handle pricing and the member can request reimbursement from CWUW for their out-of-pocket costs, if needed.

A referral + financial aid partnership: C4W will refer women to my practice, and will contribute $500 per year ($250/6mo) to their care. I will be responsible for invoicing CWUW when covered sessions are finished, and collecting a survey from the member. The member will be responsible for any balance after my discount/CWUW's contribution.

Other:

Required

Describe your ideal bi-directional referral process. *

If you become a referral + financial aid partner, what kind of discount would you be willing to give to the member as a result of CWUW's $250 contribution toward the cost of their care? Examples: free sessions, session or package discounts, etc. Type N/A if you want a referral only partnership.
*

What else would you like for us to know about your practice and services? *

Please provide some dates and times in January 2024 that you are able to meet about our potential partnership. *

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