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Emotional Support Program MHP Questionnaire
Please tell us more about your services and interest in partnering with New Day Foundation to serve families impacted by cancer through emotional support.
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Full Name
*
Your answer
Mental Health Professional Title and Credentials – Please specify the initials included after your name
*
Your answer
License Number, State, and Expiration Date:
*
Your answer
Contact Phone for Clients to use:
*
Your answer
Email Address:
*
Your answer
Available methods of offering therapy
*
In person
Virtual - video call
Phone call
Hybrid
Primary Business Address:
*
Your answer
Preferred mailing address for compensation, if different than business address:
*
Your answer
Please tell us about why you are interested in partnering with the Emotional Support Program through New Day Foundation.
*
Your answer
Do you have experience working with individuals with a current cancer diagnosis, a family member of someone with cancer, or grief related to cancer?
Yes
No
Other (please give more information below)
Clear selection
How many clients do you have capacity to serve simultaneously? (i.e. 3 clients or as needed)
*
Your answer
What is your typical session fee?
*
Your answer
Are you willing to charge New Day Foundation a reduced rate for our families' sessions? (Please note, a reduced rate will allow us to cover more sessions for clients. (ex. $60, $80, $100, etc)):
Your answer
Insurances Accepted:
*
Your answer
Mental Health Services that you are able to provide (please check all that apply):
*
Individual Therapy – Children (age under 10)
Individual Therapy - Adolescent (age 10-19)
Individual Therapy - Adult (age 18+)
Individual Therapy – Senior (age 70+)
Couples Therapy
Family Therapy
Group Therapy (please describe group(s) available in space below)
Other (please describe in space below)
Required
Expertise In or Specialties that you provide: (please check all that apply)
Cancer
Terminal Disease
Grief and Loss
Trauma
Anxiety
Depression
Adjustment to Life Events
Body Image/Sexual Health
OCD
ADHD
Substance Abuse
Other:
Languages spoken/signed and understood (in addition to English):
Your answer
If you provide a faith-based approach upon request, please indicate faith:
Your answer
Please tell us about your appointment schedule availability:
Mornings
Afternoons
Evenings
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Mornings
Afternoons
Evenings
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please provide explanation of questions answered "Other" (please indicate the question) or additional information (example, Spanish-speaking clients only or 3 active clients at a time):
Your answer
Have you reviewed the program overview and mental health professional agreement documents?
*
Yes
No
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