Organization Intake

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Organization Intake

Thank you for taking the time for your BMHV representative to get to know your organization a little better. As an organization geared toward building capacity, we are also understanding of our own capacity goals and limits.

With that in mind, we are seeking organizational partners that can actively add value and capacity through our services and programming, attending and engaging during our monthly meetings, and helping us with promotion and getting our word out.

Please complete the following intake form and we will be in contact with you shortly.

Organization Name *

Organization Mission *

Point of Contact Name *

Point of Contact (Title)

Point of Contact (Cell Phone Number)

Point of Contact (Office Number) *

Point of Contact (Email) *

2nd Point of Contact Name

2nd Point of Contact (Title)

2nd Point of Contact Name

2nd Point of Contact (Cell Phone Number)

2nd Point of Contact (Office Number)

2nd Point of Contact (Email)

Your Organization's Needs *

Please list your top 3 needs.

BMHV can provide the following, according to the needs you listed above. Please choose the area(s) of desired support. *

Solution 1: Healing Initiative Services

Solution 2a: Health Justice Programs

Solution 2b: Health Justice Advocacy

Solution 3a: Resource Partners

Solution 3b: Resource Toolkit

Solution 4: Education, Research and/or Listening Sessions Support

Solution 5: Workshops, Organizational Training and Consulting

Other:

What is your organizations current capacity? *

(Ex: Available Budget, Human Capital, In-Kind donations, Location/Space, etc...)

Which of the following can your organization contribute to help meet BMHV needs? *

Share Awareness: Advertising, Social Media, Email/ListServ

Increase Capacity: Community Partnership Connections, Volunteers

Operational Budget Funding (3 options)

Black Therapy Fund: $250 (1 person/month), $750 (1 person/quarter), $75,000 (100 people yearly)

Mental Health Programming: Youth, Senior Citizens, Men, Women

Mental Health Research

Required

How would you like to be communicated with? *

What would you like the frequency of our communications to be? *

Would you like to be added to our newsletter email list? *

Yes

Other:

We host a monthly Village Meeting, where we do a check up and check in with our active partners, members and staff. Active partners are invited and encouraged to participate. Does your organization have 1 (preferably 2) individuals, who will be designated, to attend our monthly meetings? *

Yes

Other:

We, at Black Mental Health Village, appreciate your time and look forward to our growing connection and collaboration in service and support to our community.

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