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Maui Mental Health Availability
Thank you for offering your support during this challenging time. Our referrals are bouncing back from volunteers who no longer have availability. We want to streamline services and connections for those in need, and are asking you to fill out this form IF YOU HAVE AVAILABILITY. This form is only for providers with valid Hawaiʻi licenses. Others can still volunteer (and see all details)
here
.
If you have any questions about this form, please contact
dr.dlogan@gmail.com
or
mauikokua@gmail.com
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* Indicates required question
Email
*
Your email
Provider first name(s)
*
Your answer
Provider last name(s)
*
Your answer
License type(s)
in Hawaiʻi
*
Psychologist (Ph.D.)
Psychologist (Psy.D.)
LCSW
LMFT
LMHC
CSAC
Other:
Required
Hawaiʻi license number(s)
*
Your answer
Are you licensed to provide services in any other state(s)? (if yes, list state(s) under "Other")
*
No
Other:
Your physical location
*
Maui
Hawaiʻi
Kauaʻi
Lānaʻi
Molokaʻi
Oʻahu
Other:
Group practice or Organization (if applicable)
Your answer
Website (if applicable)
Your answer
Cell Phone
Your answer
Office Phone
Your answer
How should referrals contact you?
*
Cell phone
Office phone
Email
Other:
Required
Telehealth offered?
*
Yes
No
In person services offered? (if yes, list area(s) under "Other")
*
No
Other:
Do you speak any other languages fluently? (if yes, list language(s) in "Other")
*
No
Other:
Have you completed Psychological First Aid Training?
*
Yes
No
Other:
Do you have specific CRISIS training?
*
Yes
No
Other:
Do you have specific TRAUMA training?
*
Yes
No
Other:
Do you have specialized FIRST RESPONDER training? (if yes, list specific training/credential under "Other")
*
No
Other:
Do you have specific expertise working with certain ETHNIC, RACIAL, or CULTURAL GROUPS? (if yes, list specific groups under "Other")
*
No
Other:
Do you have specific expertise working with:
Children / Youth
Families
Older adults
LGBTQIA+
People with SMI
Addiction services
Other mental health providers
Other:
What types of referrals can we send?
Immediate / Acute (1-2 sessions)
Short-term (1-3 months)
Long-term (4+ months)
Coverage for a set time for drop in services
Group service(s)
Other:
Insurance accepted?
Pro Bono (1-2 sessions only)
Pro Bono (1-2 patients, may be long term)
HMSA
HMSA Quest
HMAA
UHA
UHC
AlohaCare
Medicare
Ohana
Kaiser (Community Provider)
Cigna
Aetna
Sliding Scale
Private Pay only
Other:
Specialties
Your answer
Any limitations in referrals (meaning who should we
not
send you)?
Your answer
Notes/Other comments
Your answer
Mahalo for your time and support of our community!
If your status changes, please email mauikokua@gmail.com
A copy of your responses will be emailed to the address you provided.
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