Flourish-Provider Questionnaire

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Name

What are your pronouns?

Please enter a valid email address.

Phone

If you have a headshot photo you would be willing to share in our provider directory, please upload it here:

Are you a solo practitioner or do you work in a group practice?

Solo practitioner
Group practice
other

Other (please explain):

Name of Practice/Organization:

Zipcode where your practice is located:

Website

Do you offer evening hours for appointments?

Yes
No

Do you offer weekend hours for appointments?

Yes
No

Do you provide virtual therapy/telehealth?

Yes
No

What are your preferred methods of communication with clients/patients?

Phone calls
EmailsText messages
OtherPlease check any/all that apply.

Other (please explain):

Which of the following licensures do you hold?

Licensed Mental Health Counselor (LMHC)Licensed Professional Counselor (LPC)Licensed Clinical Counselor (LCPC)Licensed Professional Clinical Counselor of Mental Health (LPCC)Licensed Clinical Mental Health Counselor (LCMHC)Licensed Mental Health Practitioner (LMHP)Licensed Clinical Social Worker (LCSW)Licensed Marriage and Family Therapist (LMFT)OtherPlease be aware that only fully or provisionally licensed practitioners may participate.

Other (please explain):

Are you licensed in the State of Missouri?

YesNo

Missouri Licensure:

Please indicate your licensure status in Missouri:

I am fully licensed.I am provisionally licensed.I am not licensed

Please upload a copy of your license here:

Non-Missouri Licensure:

Please indicate a state outside Missouri in which you are licensed:

To enter multiple states, please click the link to "Add another response".

Please indicate your licensure status in this state:

I am fully licensed.I am provisionally licensed.I am not licensed

Please upload a copy of your license here:

Do you carry professional liability insurance?

YesNo

How much liability insurance do you carry?

Please upload proof of insurance that includes date of expiration:

Are you a board certified telemental health provider (or DCC)?

YesNo

Treatments/Therapies:

Please indicate which of the following you have EXPERTISE in:

Cognitive Behavioral Therapy (CBT)	Dialectical Behavior Therapy (DBT)
Motivational Interviewing	Psychodynamic
Eye Movement Desensitization and Reprocessing (EMDR)	Family Systems Therapy/Treatment
Trauma-Informed Treatment	Other

Please explain what other treatments/therapies you have expertise in:

Please indicate which of the following you USE in your therapy practice:

Cognitive Behavioral Therapy (CBT)	Dialectical Behavior Therapy (DBT)
Motivational Interviewing	Psychodynamic
Eye Movement Desensitization and Reprocessing (EMDR)	Family Systems Therapy/Treatment
Trauma-Informed Treatment	Other

Please explain what other treatments/therapies you use in your therapy practice:

Please tell us about how you settled on the treatment(s) you use in practice:

Have you had ethics training in the past year?

YesNo

What services do you provide?

Individual CounselingGroup CounselingFamily CounselingOther

Please list any languages in which you are fluent:

Do you offer a sliding fee scale?

YesNo

Do you accept insurance?

YesNo

Do you accept Medicaid/Medicare?

YesNo

The Scholarship Foundation intends to cover the cost, at a negotiated or mutually agreeable rate, of therapy for students we refer as long as funds are available. How many students from The Scholarship Foundation would you be able/willing to work with?

Please enter a number.

Please tell us about yourself, including demographics (race, gender), educational background and training, as well as any considerations that are important to you and your practice:

Please share demographic information about the population(s) you serve:

What types of communities/populations do you have experience providing mental health care for?

College studentsBlack, brown, Indigenous, Asian, and/or Latinx peopleImmigrants/refugeesLGBTQIA+/Queer/Trans PeopleIndividuals with disability(ies) or chronic health conditions

The students of The Scholarship Foundation of St. Louis are all low income and most come from families in which there are significant economic stressors. 43% identify as Black, 35% as white, 9% as Hispanic/Latino, 5% as multiracial, and 3% as Asian. An increasing proportion of our students identify as LGBTQ and do not subscribe to the gender binary. What equips you to work with these students?

Why do you want to work with The Scholarship Foundation’s Flourish program?:

Are you a bot?

Yes

Please click the button below to complete this form & proceed to the Flourish Provider Agreement:

Flourish - Provider Agreement

Flourish, a program of The Scholarship Foundation of St. Louis, is a mental health program that provides support to Foundation students who desire access to high-quality mental health care. Flourish grew out of the recognition that the current stressors, not to mention systemic factors, facing students are many and significant. The Foundation believes that providing access to high-quality, affordable mental health care is critical to students’ well-being and success.

This agreement is not legally binding; it is an acknowledgement of the commitment made as a provider, as well as the expectations for The Scholarship Foundation and students participating in the Flourish program.

In support of students participating in Flourish, The Scholarship Foundation will:

Recruit and review licensed and provisionally licensed providers for inclusion in the Provider Directory. This requires verification of licenses for the provider and their supervisor; proof of liability insurance; and other documents as warranted.
Request updated licensure and liability insurance information as required.
Provide an intake process to students, which includes informed consent, pre-survey, education, and orientation to the Flourish program. Students will receive a copy of their completed informed consent as part of the intake process.
Reimburse providers providing care to Scholarship Foundation students at a rate of $100 for a 45-minute session and $150 for a 60-minute session. Reimbursement requests will be submitted to the Foundation online. The Scholarship Foundation will issue approved reimbursement on the Tuesday that follows the date of reimbursement submission.
Reimburse providers for students to receive up to 24 sessions per year, with the year running from August-July.
Draft a provider profile, share with the provider for review and edits, and post on the Flourish Provider Directory.

Through their participation in Flourish, Scholarship Foundation students will:

Complete the intake process, which includes informed consent, pre-survey, educational videos, and an orientation conversation with the Advising Director, and which concludes with students receiving access to the provider directory.
Be responsible for selecting a provider from the provider directory and scheduling an initial consultation and follow-up appointments.
Adhere to provider expectations on attendance and cancellation policies, once communicated. Failure to do so may result in withdrawal from the Flourish Program.
Provide their unique Flourish-ID to their provider, which is necessary for the provider to seek reimbursement from the Foundation.

By participating as a provider to students through FLOURISH, providers will:

Provide therapy to Scholarship Foundation students at the agreed upon reimbursement rate of $100 for a 45-minute session and $150 for a 60-minute session.
Provide a valid W-9 when first submitting for reimbursement; submit requests for reimbursement routinely via the Foundation’s online form.
Submit updated copies of state licenses and proof of liability insurance upon expiration and as requested by the Foundation. Failure to do so may result in removal from the Provider Directory and suspension of reimbursement until updated documents are provided.
Notify the Foundation if a Flourish student misses more than one scheduled therapy session.
Notify the Foundation if, for any reason, they are no longer able to serve as a provider due to relocation, retirement, or other circumstances.
Support student clients in developing a sustainable mental health plan including, but not limited to, planning for continued access to high-quality, affordable therapy.

Provider Name

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