2023 NAAAP Wellness Therapy Fund Application for Providers

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Email *

NAAAP-Chicago's Wellness Therapy Fund Application FOR PROVIDERS

Welcome to the PROVIDER application form for NAAAP-Chicago's Wellness Therapy Fund program (NWTF)!

The goal of this program is to make psychotherapy as available, accessible, and approachable as possible to the Asian community in the Chicagoland area.

The information on this form will only be used in connection with the work of the Chicago chapter of the National Association of Asian Americans (NAAAP-Chicago) and will only be accessible to designated individuals directly involved in this program (such as our Treasurer and Wellness Program Chair). Filling out this form does not guarantee immediate placement into this program. Please review our terms and conditions and fill out the form below. If you do not review and sign the terms and conditions, we are unable to accept your application.

In order to be considered for this program, you MUST be:

(1) a licensed mental health professional in the state of Illinois,
(2) able to provide culturally responsive clinical services to adults at least 18 years old*, and
(3) listed on CAATCH’s online directory. If chosen to join NAAAP-Chicago's Wellness Therapy Fund program as a provider, you will be partnering with NAAAP-Chicago to address our community's financial and cultural barriers to wellness.

Description of the NAAAP Wellness Therapy Fund:
Generally speaking, the selection process for this program operates on a needs-based and first-come, first-served basis. NWTF recipients will receive from NAAAP-Chicago financial assistance of up to $100 per session, for up to 8 sessions (at least 53 minutes in length) per application round. In order for individuals to continue receiving subsidized therapy, the recipient must reapply during each application round. Each NWTF recipient will receive a unique voucher code to help protect their identity. Providers are to notify NAAAP-Chicago via this unique voucher code when sessions have been attended so NAAAP-Chicago can pay providers directly for sessions rendered. NAAAP-Chicago will receive no other information about the sessions; NAAAP-Chicago is simply funding sessions attended.

Please note, agreeing to participate in the NWTF is not a guarantee that the recipients of the Wellness Therapy Fund will choose to work with you. Each recipient chooses which of the participating clinicians they feel most aligned. As with any therapy service, they also have the right to terminate services and/or change providers.

Thank you for your interest in helping NAAAP-Chicago further its mission of destigmatizing mental health for our community! Further information will be provided once your application has been approved and you’ve been accepted into the program.

*At this time, NAAAP-Chicago's Wellness Therapy Fund is available to IL residents 18 years and older only.

Email *

Name *

Phone number *

Age *

18-24

25-29

30-39

40-49

50+

Required

Are you Fully Licensed?

Fully Licensed (I am able to provide psychotherapy/medication management/clinical services without being supervised)

Provisionally Licensed (I require clinical supervision in order to provide psychotherapy/other clinical services)

Clear selection

Active State Licenses (e.g. IL123456...Please include the state)
*

Type of Provider

Clinical Psychologist (PsyD/PhD)

Psychiatrist (MD)

Clinical Social Worker (LCSW)

Professional Counselor (LPC)

Marriage & Family Therapist (LMFT)

Mental Health Counselor (LMHC)

Other:

Clear selection

Please tell us about why you would like to join NAAAP-Chicago's Wellness Therapy Fund program as a clinician.

How many years of experience do you have working as a clinician/psychotherapist?

How many years of experience do you have working with the Asian population?
*

Can you provide clinical services in languages other than English? If yes, please list.

Do you have any clinical specialities? What areas do you treat?

Populations you serve (Age)
*

18-24

25-29

30-39

40-49

50+

Are you listed on CAATCH's Therapist Directory? To apply, visit https://www.caatch.info/membership
*

Yes

Ethnic Background, can check all that apply
*

Central Asian (Afghani, Armenian, Azerbaijani, Georgians, Kazakh, Kyrgyz, Mongolian, Tajik, Turkmen, Uzbek)

East Asian (Chinese, Japanese, Korean, Okinawan, Taiwanese, Tibetan)

Southeast Asian (Bruneian, Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Timorese, Thai, Vietnamese)

South Asian (Bangladeshi, Bhutanese, Indian, Maldivians, Nepali, Pakistani, Sri Lankan)

Native Hawaiians and Pacific Islanders (in the U.S. Jurisdictions & Territories) Carolinian, Chamorro, Chuukese, Fijian, Guamanian, Hawaiian, Kosraean, Marshallesse, Native Hawaiian, Niuean, Palauan, Pohnpeian, Papua New Guinean, Samoan, Tokelauan, Tongan, Yapese

My ethnic background was unfortunately overlooked and I will tell you more below.

Required

What else could we include to make this process more inclusive for your?

Is this your first time applying to be a provider for the NWTF - NAAAP Wellness Therapy Fund program?

Yes

Would you like to speak with someone from NAAAP-Chicago's Wellness program? If so, what would you like to discuss?

In addition to NAAAP's Wellness Therapy Fund, what else would you like to see in the future to help address mental health disparities for Asian Americans in the Chicagoland area?

Would you like to be a part of our mailing list?
*

Yes

By applying for this fund, you agree to these statements (Check ALL):
*

I recognize that this is an application to take part in a program aimed to reduce financial barriers to mental health care for Asians who have historically been excluded from high quality, culturally appropriate treatment.

I will receive a maximum of $100/session while providing services for NWTF recipients for a maximum of 8 sessions (at least 53 mintues in length) per application round. I recognize all sessions must be rendered and reimbursed by sending an invoice to NAAAP-Chicago.

I agree that NAAAP-Chicago is only responsible for payment of the sessions attended by the NWTF recipient (which is up to 8 sessions per application round). Any late cancelation or no-show fees accumulated are to be managed privately between me as the providing therapist and the NWTF recipient, as these are not included as part of this therapy fund.

I understand that the duration, frequency, and therapy goals are co-constructed between me as the provider and the NWTF recipient as the client. NAAAP-Chicago will NOT receive treatment plans, sessions notes, or any other confidential information outside of notifications that a session has been attended through a uniquely generated voucher code so the session payment can be rendered.

I have the ability to provide in-person and/or telehealth services (online or phone therapy) in the state of IL. I can inform NWTF recipients if I am able to provide services in alternative locations or not. NAAAP-Chicago is not responsible for session cancelations or interruptions due to NWTF recipients’ change of physical location.

I will uphold my ethical, legal, and professional standards by providing quality care. I am solely responsible for adhering to my professional responsibilities and legal requirements, including HIPAA and other compliance and reporting obligations, and for carrying appropriate liability insurance.

I understand that NAAAP-Chicago nonprofit, its volunteers, partners, and sponsors provide no warranties and have no liability for any services provided by or any issues related to therapists on the CAATCH Therapist Directory.

I relieve and indemnify NAAP-Chicago for all liability relating to participants or issues in this program.

I will not direct racism, anti-Blackness, homophobia, sexism or any other form of hatred toward NWTF recipients, NAAAP-Chicago, its volunteers, partners, or sponsors who are making this program of financial assistance possible.

Required

Terms & Conditions: You confirm that you, as the individual submitting this form, are the named clinician intending to provide therapy services, that you are a licensed mental health professional in the state of Illinois, and that if you accept a client, that you are fully competent to provide clinical services in the areas of specialization likely needed to treat the client. If you are accepted to be a provider in NAAAP-Chicago’s WellnessTherapy Fund program, you are agreeing to accept NAAAP-Chicago Wellness Therapy Fund recipients as clients, when professionally appropriate. You will be accepting a maximum payment of $100 per session, for a maximum of 8 sessions per application round. Subsequent finacial assistance through the NWTF requires recipient reapplication.

You are agreeing to uphold your ethical, legal, and professional standards by providing quality care.You acknowledge that NAAAP-Chicago, its partners, and its sponsors provide no warranties and have no liability for any services provided by or any issues related to therapists. You acknowledge the CAATCH Therapist Directory is a non-exhaustive, voluntary listing of mental health professionals who are attempting to provide quality, culturally competent services but who are not endorsed by or are agents of NAAAP-Chicago. Therapists are solely responsible for adhering to their professional responsibilities and legal requirements, including HIPAA and other compliance and reporting obligations, and for carrying appropriate liability insurance. Each therapist participating in the NWTF program agrees to relieve and indemnify NAAAP-Chicago for all liability relating to participants or issues in this program. By clicking yes below, you acknowledge that you fully understand the terms and conditions above and, if selected as a clinician, freely consent to abide by all rules and policies associated with the NAAAP-Chicago.

Yes, I agree to the above Terms & Conditions

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear selection

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Submit

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