Become a Provider for The Mama Wellness Foundation
Thank you for your interest in partnering with The Mama Wellness Foundation. At the Mama Wellness Foundation, we are dedicated to supporting brown mamas on their wellness journey by offering affordable or free therapy sessions. Your unwavering commitment to maternal mental health has the potential to create a lasting impact on the lives of our mothers and their families, shaping their well-being for years to come. Please attach copies of any accompanying documents at the end of the form: (Resume, Certifications, License, Professional Liability Insurance etc.)
Requirements:
License Therapist Must be Licensed in Louisiana and/or Texas. Provisional licensure is accepted.
Intern Therapist are accepted. Must be in a graduate level program.
All The Mama Wellness Foundation's MHP must carry appropriate liablity and malpractice insurance.
TMWF medical pproviders must be committed to excellence, integrity, and social justice - seeking improvement in the care of black women.
Medical providers must be availabe to support one pro bono client to accept paid referrals and opportintues in our network.
Benefits:
Free access to all of The Mama Wellness Events (Excluding Wellness Retreat)
Paid Opportunites such as speaking and workshop training
Be apart of the work to reduce and/or prevent maternal mental health in the black community
Peer Networking & Opportunities
Featured on The Mama Wellness Foundation Website
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Race/Ethnicity?
Black/African American
Hispanic
White
Asian
Middle Eastern
Native American
Other
Email
example@example.com
What is your Gender?
Male
Female
Trans
Non-Binary
Other
Phone Number
Please enter a valid phone number.
What is your office phone number?
Please enter a valid phone number.
What is your office address? N/A if not applicable.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website URL (N/A if you do not have one)
Social Media Username (N/A if you do not have one)
Do you work as part of an agency, solo, or group practice?
Agency
Solo
Group
Other
What type of provider are you?
Psychiatrist
Psychologist
Licensed Psychologist
LMFT
LPC
LCSW
Pre-licensed Therapist/Counselor
Student Currently Training in a Clinical Post Graduate Program
Other
Please list your highest level of Education.
Are you licensed?
Yes
No
If unlicensed - Supervisor Name
If licensed - License No. & State
NPI Number
NCQA Number
Please list your professional liability insurance info. N/A if you don't have your own insurance.
Have your license been in suspension by accrediting board at any point in the last 5 years?
Yes
No
If yes, please list when and the reason
All counseling will provide services to adults over the age of 18. Have you had any experience in this age setting?
Yes
No
Please indiciate any or all of the types you are experienced in....
Pregancy
Postpartum Depression
Motivational
Identity
Motherhood
Relationships/Friendships
Parenting/Co-Parenting
Financial Concerns
Anger Management
Other
Are there any areas you would prefer NOT to work with or would feel triggered by?
Currently our sessions are virtual and six week long. Are you able to offer your session virtually?
Yes
No
Would you be interested or able to see more than 1 TMWF client during the 6 week period (donating more than 1 hour per week)?
Yes
No
If yes, please list how many clients you would like to see?
Should the mother choose to, would you be open to continuing services beyond the six weeks? This would be a separate agreement between you and the mother. You would need to set your own hours and bill insurances.
Yes
No
What are the days/hours you are available for 45min-1 hour per week?
What is your out of pocket rate or range?
Please list all insurance that you accept.
Is there anything else you would like us to know?
Please upload any copies of resumes, certifications, etc.
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