The Mental Wellness Collective Texas Flood Relief Provider Application

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Thank you for your interest in partnering with The Mental Wellness Collective and Safe Haven Counseling to offer therapy to those impacted by recent flooding in Texas.

Selected providers will deliver up to 10 therapy sessions per client, reimbursed at $50 per 50-minute session.

Please complete the application below. Submitting this form does not guarantee selection. You will be contacted for a virtual interview if selected.

Priority will be given to those serving under-resourced and flood ridden areas as well as those specifically impacted by the loss of a loved one or first responder who have cared for those impacted by Texas flooding.

You must be licensed and verified (LMSW, LCSW, LPC, LMFT ) through BHEC to be selected, and have trauma-informed training or experience working with crisis/disaster-impacted clients. You must also be on the Safe Haven Counseling provider page found here https://safehavencounselingtx.com/resources. Please fill this out if you have not already before submitting your application.

Please email connect@the-mwc.org for questions

Email *

Record my email address with my response

First Name *

Last Name *

License type + number (LPC-Associate, LCSW, LMFT, etc) *

Practice name *

Preferred email *

Preferred phone number *

Website *

Practice address including zip code. If virtual only, please indicate. *

Do you carry liability insurance, minimum $1,000,000 coverage? *

yes, and will provide proof of coverage

not yet, but willing to

Do you have experience with trauma, crisis care, or disaster mental health? If yes, please list. *

I am interested in working with *

Children

Teens

Adults

Families

Required

Language(s) spoken to provide therapy

Why are you interested in serving those affected by the Texas flooding? A brief statement is sufficient and you consent to allowing us to share your response as we promote our working relationship. *

Please read and check each box to acknowledge your agreement: *

I am a licensed mental health provider in the state of Texas.

I will offer up to 10 therapy sessions per client reimbursed at $50 per 50-minute session.

I acknowledge invoices must be sent by the 5th of the month after completing services (By Sept 5 for Aug payment) otherwise I will not be reimbursed for services provided, nor will I charge the client for late-billed sessions.

I agree to participate in a virtual interview to be selected as a preferred grief + trauma provider

I allow The Mental Wellness Collective to share my practice info on their website/social media if selected.

My information has been added to the Safe Haven Counseling Provider Resource List

I understand I am not an employee of The Mental Wellness Collective.

I have reviewed and align with the mission of The Mental Wellness Collective at www.the-mwc.org.

I understand submitting this application does not guarantee selection.

Required

Please type your full name as your digital signature. *

date *

YYYY

Send me a copy of my responses.

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