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Care Connections™ Mental Health Professionals Partnership Form

Thank you for your interest in joining the Care Connections™ Referral Network with A Mindful Resource Inc.

A Mindful Resource Inc. is a Dallas-based trust-first, prevention-based nonprofit mental wellness organization focused on connecting communities with culturally competent mental wellness resources.

This form helps us learn more about mental health professionals so we can make appropriate referrals through programs such as:

• Bro Chill Men’s Wellness Initiative

• Help A Brother Therapy Support Program

• Youth Emotional First Aid

• Community Mental Wellness Navigation

Completion of this form does not guarantee referrals, but helps us determine the best fit for collaboration an in d community referrals.

Full Name

Professional Credentials

Professional Credentials
A
B
C
D
E
F
G

Practice / Organization Name

Email

Phone

Website

Practice Location

Are you located in the Dallas–Fort Worth area?

License Number

Licensing Board

Years of Clinical Experience

Years of Clinical Experience
A
B
C
D

What services do you provide?

What services do you provide?

What populations do you specialize in?

What populations do you specialize in?

Do you have experience working with underserved or culturally diverse communities?

Please describe your approach to culturally responsive care

Do you offer Telehealth?

Languages Spoken

Which payment options do you accept?

Which payment options do you accept?

If sliding scale is offered, please describe

Community Collaboration

Are you open to receiving referrals from A Mindful Resource Inc.?

Would you be interested in participating in any of the following?

Would you be interested in participating in any of the following?

Help A Brother Initiative

Our Help A Brother initiative helps Black men access therapy support.

Would you be open to accepting reduced fee referrals when available?

Why are you interested in partnering with A Mindful Resource Inc.?

Anything else you'd like us to know?

Consent Statement

I confirm that the information provided is accurate and that I hold an active professional license in good standing.

Consent StatementI confirm that the information provided is accurate and that I hold an active professional license in good standing.