Mental Health Fund
**PLEASE NOTE** We have currently reached capacity for this program. New submissions of this for will be added to our waitlist as we seek additional funding to continue to support the program.

You will only be contacted if your file is sent to a clinician for further review. Application is not a guarantee of acceptance.

----

We're partnering with mental health clinicians to make sure that families can get the support they need.  If you need mental health support and don't have coverage, or know someone in need, please fill out the form below.

The completion of this form is required in order to request to be a part of this program. Submission of this form is not a guarantee that you will be accepted into this program. We will do our best to get back to you within 7 business days.

Applicants should:
*Identify as Black if applying for mental health support for yourself
*OR have children who identify as Black if applying for mental health support for your child
*NOT have private health insurance (if you do have private health insurance, you are not eligible for this fund but can contact us at info@parentsofblackchildren.org for a list of low cost providers)

This program will provide you with 3 sessions with a clinician free of charge. You can discuss with your provider whether further sessions are needed.

This form is considered confidential. No information in this form will be shared with anyone outside of the Parents of Black Children team without your consent.

A copy of this form can be sent to the email you provided upon submission if you request it.

Follow the link below to go back to the Parents of Black Children website
https://parentsofblackchildren.org
Sign in to Google to save your progress. Learn more
I am... *
Your Name *
Name of person requesting services *
Your phone number *
Your email address *
Where are you located? *
Please confirm that you identify as a Black person or as parent of a Black child *
Please confirm that you do NOT have private health insurance *
Who are you submitting this application form for? *
What is your age/the age of the person for whom you are applying? *
Are you currently employed? *
What is your annual household income? *
What support are you requiring? Select all that apply *
Required
Do you currently have any diagnosed mental health conditions? *
Have you received private therapy before? *
If you have NOT received private therapy before, why not? Select all that apply.
In as much detail as you are comfortable sharing, please describe the mental health concerns you/your child are currently experiencing. This will be shared only with the selected clinician. *
Please select your preferred clinician. Please go to https://bit.ly/39Vyb78 to download a full description of each clinician's area of specialty. *
If this program was not in place, how would your mental health needs be addressed? *
I understand that information collected in this form is private and confidential and will only be shared with the clinician of my choosing. *
I understand that Parents of Black Children will share all relevant information in this form to the relevant clinician. The clinician will contact me for an appointment. I give my consent to have the information shared in this form provided to my indicated clinician. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside parentsofblackchildren.org. Report Abuse
Google Forms