Mental Health Support

We are pleased to launch our mental health supports for children, youth, and adults. We will also be offering parenting support for parents and caregivers who are helping their children with mental health challenges. Our mental health supports are for residents of Toronto. This form is considered confidential. No information in this form will be shared with anyone outside of the Parents of Black Children team without your consent. A copy of this form can be sent to the email you provided upon submission if you request it.

First Name

Last Name

Email*

Phone Number

What is the best way to contact you?Please enter dataPhoneEmail

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

Name of Person Requesting Services (First and Last)*

What is your age/ the age of the person for whom you are applying?*

Please confirm that you identify as a Black person or as a parent of a Black child*

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

What is your postal code? You must be a resident of Toronto to use our virtual mental health services.*

By using these services you are confirming that you are a living in the city of Toronto*

Yes

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

Have you received private therapy before? *

Yes No

if you have 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

Are you currently employed?*

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

Do you currently have any diagnosed mental health conditions?*

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.*

If this program was not in place, how would your 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

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

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