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YOUTH Mental Health Support

This form is considered confidential. Information submitted will be shared only with the therapist providing your support. No one else outside of the Parents of Black Children team will receive this information without your consent. A copy of this form can be sent to the email you provided upon submission if you request it. Please note this form is to be completed by the parent or guardian of any child seeking services between the ages of 4-18 years old. Youth 18-25 can complete the form on their own.

First Name of child/youth

First Name of child/youth

First and last name of parent/guardian*

Email*

Phone Number

What is the best way to contact you?

Consent

By completing this form, I consent to have this information, including personally identifying information, shared with the Parents of Black Children Mental Health Support Services. We will be offering Single-Session (one-off) Therapy. One-Off Therapy is where the client and thearpist agree to meet to help the client deal with a specific concern in one session. The intention of this therapy is to help the client in one- single session and additional resources will be provided if neeeded. Do you agree to this consent and the Single-Session therapy?

Consent*

Yes

Mental Health Form Questions

I am....*

Requesting services for my child requesting services for myself

What region do you live in? (Other)

What is the age of the child/youth for whom you are applying?*

Please confirm the identity of the child/youth seeking services *

Yes, I identify as a Black person or a parent of a Black child

Please confirm if you have private health insurance.*

I do not currently have private health insurance I do have private health but I am still in need of counseling services

Has the child/youth received private therapy before? *

Yes No

If they child/youth has NOT NOT received private therapy before, why not? Select all that apply.

I have not previously had a reason to need private therapy Cost Time Could not find a provider Other

Has the school recommended mental health supports for the child/youth?*

Yes, I am currently employed No, I am currently unemployed

How would you rate the mental health of the youth/child you are applying for?*

Please describe the reason(s) you are seeking mental health support? Please share as much detail as you are comfortable sharing. This will be shared only with the clinician.*

Does the child/youth have any diagnosed mental health conditions?*

If this program was not in place, how would the mental health needs be addressed?*

I would have done nothing and therefore would not have been able to access therapy I would have waited for another free service

Are you worried about self-harm, suicide or suicide ideation/thoughts?*

Yes No

I understand that Parents of Black Children will share all relevant information in this form to the relevant clinician. The clinician will contact me for an appointment. I give my consent to have the information shared in this form provided to the clinician.*

I agree

I understand that information collected in this form is private and confidential and will only be shared with the clinician.*

I agree

If you have any questions please contact us at: info@parentsofblackchildren.org

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