Information and Referral Fact Sheet for Mental Health Professionals

Mental Health Association of Greater St. Louis	1905 S. Grand Blvd. St. Louis, MO 63104 314-773-1399 Info@mhagstl.org	The Mental Health Association is a United Way Agency. Click on the picture to go to the United Way website.

Information and Referral Fact Sheet for Mental Health Professionals.

Please complete this form and press the "submit" button below when you are finished. For group practices, please complete one form per person.

Name

Agency/Group Practice

Office Address #1 Phone #1
City State Zip Fax #1

Office Address #2 Phone #2
City State Zip Fax #2

E-Mail Near Bus Service? Yes No

Near MetroLink? Yes No

Home Address (for MHA office use only)

City State Zip

Fees: $ per Hour $ per Half-Hour

Degree(s): Licensed in MO IL License #

Sliding Scale	Yes No	Internet Counseling	Yes No
Medicare	Yes No	Phone Counseling	Yes No
Medicaid	Yes No	Home Visits	Yes No
Other Insurance	Yes No	Wheelchair Accessible	Yes No

Specializations (e.g. substance abuse, marital, eating disorders, etc.):
Populations Served (e.g. children, adolescents, adults, elderly, couples, families, other)
Types of Services/Treatment Provided (e.g. groups, financial assistance, housing, medication, testing, etc.):
Treatment Modality (e.g. Cognitive, Psychodynamic, Reality, etc.):
Other information (e.g. Foreign languages, Disability Accommodations, Licensure Supervision, Christian Counseling, etc.):

I would like to be a respondent to Open Mind, the Association's Q&A educational column that appears weekly in the Suburban Journals and other Missouri newspapers.	Yes No
I would like to join the Association's Speakers Bureau.	Yes No
I am interested in providing training for Law Enforcement.	Yes No
I'm interested in helping with depression screenings at community events.	Yes No
I am currently a member of the Mental Health Association.	Yes No
I want to join the Mental Health Association. (Complete the items below.)	Yes No

New Membership Renewal

Student/Senior $10 Individual $15 Family $25 Professional $35

Group Practice or Human Service Provider $100 Organizational/Business* $100

Contributor $100 Sponsor $250 Sustainer $500 Patron $1,000

Benefactor $2,500

* Organizational memberships include up to five individuals. Each additional individual is $20.

All contributions are tax deductible to the extent provided by law. Consult your tax advisor.

When you have completed the form above, click on the "Submit" button below.

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