Sonoma County Black Forum Black Therapy Application

Sonoma County Black Forum Black Therapy Application

The Sonoma County Black Forum Black Therapy Fund Voucher Program offers up to 12 sessions of mental health counseling, from culturally competent therapists, for up to 234 qualifying Sonoma County Residents. Each session is valued at $150 per session. This funding is being supported in whole by federal award number SLFRP0246 awarded to the County of Sonoma by the U.S. Department of the Treasury through the American Rescue Plan Act of 2021. The Sonoma County Black Therapy Fund program is administered by Sonoma County Black Forum.
What Services Do Vouchers Cover?

Mental Health Services in-person or via telemedicine. Although you and your provider will determine how many sessions you need, this program will provide a total of 12 sessions. Participants will be provided a list of partner therapists. Once a provider has been selected, participates are responsible for scheduling initial consultations and follow up therapy sessions.
Do I qualify for a voucher?

Are you experiencing mental health challenges/issues? You qualify. Are you in need of mental health support? You qualify. Need funding support to cover costs of services? You qualify. Applicants must be current Sonoma County residents (minimum 6 continuous months). The Sonoma County Black Forum will not deny assistance to an otherwise eligible household on the basis of race, ethnicity, gender, sexual orientation, or religion. This program is open to all Sonoma County residents regardless of immigration status. Sonoma County Black Forum will not require applicants to state their immigration status.
Who Will See My Information

Applicant information provided in the application process will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding. For information addressing concerns about disclosure of Personal Identifiable information in ARPA Community Resilience Program Data Reporting, please click on the Data Collection and Release of Information link below.
Data Collection and Release of Information
Digital Signature*

Clear
Application

Please provide the information below to participate in the Sonoma County Black Forum Black Therapy Voucher Program. Your information will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding.
Name*

First Name Last Name
Date of Birth MM/DD/YYYY*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred method for us to reach you*

PhoneEmailText
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Please upload your current lease/rental agreement or other current forms of Documentation below, such as rent receipts, cancelled checks or money orders, utility bills, etc. TWO CURRENT DOCUMENTS ARE REQUIRED. In order for your application to be reviewed, it must include two current documents with your first and last name on them.
Documentation #1*

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancelof
Documentation #2*

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancelof
Marital Status*

Single (never married)Married, or in a domestic partnershipWidowedDivorcedSeparatedPrefer not to answer
Total Number of Children under 18*
How many family members, including yourself, do you currently live with?*
Are there multiple families living in this household?*

YesNo
Annual Household Income*
Example: $10,000.00
What California assistance program do you currently or anticipate accessing to support you? Select all that apply.*

SNAP - Supplemental Nutrition Assistance Program/CalFreshTemporary Assistance for Needy Families (TANF)Head Start and/or Early Head StartChildren's Health Insurance Program, Childcare Subsidies through the Child Care Development Fund (CCDF) Program, or MedicaidNational School Lunch Program (NSLP) and/or School Breakfast (SBF) ProgramsPell GrantSupplemental Security Income (SSI)Women, Infants, & Children (WIC)Unemployment Insurance programMedicare Part D Low-Income SubsidiesSection 8 VouchersLow-Income Home Energy Assistance Program (LIHEAP)Household receiving services provided by Tribal governmentsNoneOther
Please list any other Government Assistance Agency you currently or anticipate accessing to support you?
How have you been impacted by COVID-19? Check all that apply:*

I was laid-off or lost my job because of COVID-19.I lost some or all of my income.I have been evicted or lost my housing because of COVID-19.I have not been impacted by COVID-19.
What are your greatest needs at this time? Check all that apply.

FoodHousingLeaving an abusive relationshipUtility shut offLow IncomeNo incomeUnemployedUnderemployedProviding for my Children 18 or youngerCaring for an elderly family member in householdComputer needsSurvival is threatenedI do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a bench, in a car, or in a park)Other
What else would you like us to know about your needs, priorities, or concerns? What additional support do you need at this time?*
Demographic Questions

Applicant information provided in the application process will be kept confidential, and helps us determine eligibility for program participation. Demographic data may be anonymously used to seek potential grant funding to support our future programs or to extend current funding. Individual data may be aggregated into anonymous group data for use in public reports and to fulfill equity standards for ARPA funding that is required by the federal government. Sonoma County Black Forum will not deny assistance to an otherwise eligible household on the basis of race, ethnicity, gender, sexual orientation, or religion.
Racial/ Ethnic Identity: Please select all that may apply to you. To add an identity not listed, please use the open description line.*

African-American/BlackAsianCaucasian/ WhiteLatino/a/x, Hispanic, or Spanish originIndigenous/Mixteco, Triqui, Chatino, or other Indigenous CommunityPuerto RicanCubanAnother Hispanic, Latino/a/xSpanish/European originNative American/Indigenous Peoples/First Nations Peoples (American Indian) or Alaskan NativeNative Hawaiian or other Pacific IslanderPrefer not to answerOther
Other Racial/Ethnic Identity that's not listed above.
What best describes your gender identity?*
Do you think of yourself as . . ,*
What is your age?*

Under 1818 - 4445 - 7475+
How did you find out about the Sonoma County Black Forum’s Therapy Voucher Program?*

Bay Area Regional Health Inequities InitiativeEARTHseedFarm to PantryLa PlazaNAACPNorth Bay Black Chamber of CommercePetaluma Blacks for Community DevelopmentSonoma County Black Forum’s website, email, word of mouthRadioMedia AdvertisementFamily Member or FriendSonoma State UniversitySanta Rosa Junior CollegeSebastopol Senior CenterOther
Affidavit of Truth: By my digital signature below, I affirm that the information I’ve included in this application is truthful to the best of my knowledge and understanding.
Signature

Clear
Session Cancellation Policy

*You must contact your therapist 48 hours prior to your scheduled appointment to cancel or the Sonoma County Black Forum will be charged for a full session.
Consent

By submitting my application for the Sonoma County Black Therapy Fund (SCBTF), I consent to the following:
I permit SCBTF partner Mental Health Providers to communicate and share basic personal data in compliance with ARPA data collection requirements. This data will include participant name, contact information, the number of sessions provided, administrative assistance with scheduling, referral agency and participant surveys. I understand that SCBTF, Sonoma County Black Forum, and its community partners will not access any HIPAA protected, personal and/or confidential information related to services provided by Partner Mental Health Providers and their clients, but are acting solely in an administrative and referral capacity.
Post Assessment Survey Request

To document the effectiveness of the program and to ensure future funding of this program, we invite you to complete an anonymous brief Post Assessment Surveys (PAS) at the conclusion of your therapy sessions. In appreciation of completing our brief survey, you will receive $25.00.
Your response will not impact funding decisions.*

Yes, I agree to take a brief survey.No, thank you
To receive a confirmation email, please provide your email below.
Should be Empty:

Sonoma County Black Forum Black Therapy Application

What Services Do Vouchers Cover?

Do I qualify for a voucher?

Who Will See My Information

Application

Demographic Questions

Session Cancellation Policy

Consent

Post Assessment Survey Request