Maui Mental Health Response
Thank you for offering your support during this challenging time. 

The Hawaiʻi Psychological Association (HPA) is coordinating contacts for mental health providers available to offer services. The Red Cross is responsible for vetting potential volunteers for emergency responses. Completing this form is not a contract to provide services. This responses to this form will be shared with the Governor's Office of Wellness and Resilience (OWR) and with providers seeking referrals and resources as appropriate.

Make sure to complete the Psychological First Aid Training (Link for PFA) by the National Child Traumatic Stress Network before you begin your shifts, and to read through the resources on the Shared Drive.

If you have any questions about this form, please contact dr.dlogan@gmail.com or mauikokua@gmail.com
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Email *
Provider name
Cell Phone
Office Phone
Group practice or Organization (if applicable)
Licensed in Hawaii?
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License type (e.g., PhD, LCSW, LMFT)
Your location
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If located in Hawaiʻi ONLY, are you a state employee? 
If located in Hawaiʻi ONLY, please provide an emergency contact for you (in case of deployment) Name, Phone, and Email
Have you completed Psychological First Aid Training? (required if volunteering for in person shifts, highly recommended for all other volunteers)

Link for PFA by the National Child Traumatic Stress Network. Please read through the resources on the Shared Drive.
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Telehealth offered?
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Able to travel to/on Maui?
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Specific Populations
Specialties
Other languages spoken
Services (please check all that apply)
Availability (please check all that apply)
Insurance accepted?
Other volunteer services you can offer (ANYTHING!)
Notes/Other comments
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