This field will be prefilled for Sites that are affiliated with a main organization, and also possibly for individual practitioners at sites.
This field will be prefilled for individual practicioners affiliated with sites. ALSO, the Individual Practitioner radio button will be prefilled and that question hidden.
ID of Directory Listing related to the prefilled Site. Used in looking up All The Things (licenses and services offered and operating hours, Oh My!)
Care Connect Provider Profile Form

NOTE: Forms received after June 2 will be reviewed, vetted, and if eligible will be displayed on the MHA Houston Care Connect Provider Search Page within about a week.

Nonprofit and for-profit organizations, group practices, solo practitioners, individuals currently under supervision, political subdivisions and government departments that provide outpatient, residential, inpatient, crisis, and supportive mental health and/or substance use recovery services to residents in the greater Houston area are encouraged to complete this form for inclusion in Mental Health America of Greater Houston’s Behavioral Health Navigation Services Resource Database. A searchable profile page for each provider also will be made available on our website. The form takes approximately 20 - 30 minutes to complete. For questions or concerns, please contact navigation@mhahouston.org.

INDIVIDUAL DEMOGRAPHIC INFORMATION

Information collected in this section will be public and used to match with client preferences. Providers may share or decline based upon their comfort level.
INDIVIDUAL LICENSING
NOTE: Individuals who provide services requiring state or national licensure or certification must demonstrate proof of their current licensure/certification in good standing to be included in the database.
SUPERVISION SERVICES
Supervision Services
Please select the type(s) of supervision you offer by using the checkbox on the left. Please also list the rate (numbers only) and whether the service is virtual or in person. You may list the rate as a minimum to maximum range (e.g., 135-200), when needed.

Rate:

Setting: 
$
/hour
$
/hour
$
/hour
$
/hour
$
/hour
In addition to the services listed above, please list any additional SUPERVISION services you offer along with rate and setting:

Service Type:

Rate:

Setting: 
$
/hour

Please click NEXT PAGE to begin completing the form.
SITE/PRACTICE INFORMATION

NOTE: If you are an individual, please answer the remaining questions in this form about yourself and the services you provide rather than on behalf of a group practice.
NOTE: Individual practitioners may enter your name and credentials OR personal practice name, but please DO NOT enter your organization's/group practice's name, as they will complete the form separately. Organizations/group practices should enter your business name (if one location) or the name of the location for which you are completing this form if you have multiple locations (e.g. ABC Behavioral Health Services - Southwest). Please complete a separate form for EACH location of your practice.

Please provide an overview of yourself/practice (similar to a website description) to introduce your background, services and/or approach to clients. This will be the highlight of your profile page. NOTE: Individual practitioners should describe their PERSONAL information, NOT those of your organization/group practice. MHA of Greater Houston reserves the right to edit for clarity, space, etc.

Organizations and group practices should enter either your 11-digit Texas taxpayer number OR your 9-digit Federal EIN number. Individuals can enter N/A.
SITE/PRACTICE LICENSING
NOTE: Organizations that provide services requiring state or national licensure or certification must demonstrate proof of their current licensure/certification in good standing to be included in the database. If you do not have licensure requirements or are unsure of the requirements, please indicate that below. Please do not re-enter individual licensure information here.
SITE/PRACTICE ACCESSIBILITY
SITE/PRACTICE HOURS OF OPERATION

Open: Close:
Weekday Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hidden - Previously Used Fields

GENERAL ORGANIZATION/PRACTICE INFORMATION


INSURANCE AND PAYMENT INFORMATION
Forms of Payment Accepted:



POPULATIONS AND ELIGIBILITY

If you are not accepting new clients, we can include you in the database as inactive. Once you are accepting new clients, please e-mail navigation@mhahouston.org,  and we can activate your account.  



SERVICES & SPECIALIZATIONS 
 
Please only select services that are currently available to the public and exclude any service that can only be obtained by current clients/members. 

NOTE: Providers in the main service area - Harris and Fort Bend counties - may list either onsite and/or virtual options. Providers located in the 10 counties surrounding Harris and Fort Bend counties must have a virtual option in addition to any onsite availability for each service you wish to have included in the database. Providers in the remaining counties in Texas should list virtual services only, as no on-site options for these providers outside will be listed:  
Outpatient Services
Please select each service you offer using the checkbox on the left. For each offered service, list the self-pay rate (not copay) and whether the service is virtual or in person. For the self-pay rate, please list the unit cost in numbers only, whether it is per session or per day. You may list your rate as “0” when the service is free, or as a minimum to maximum range (e.g., 135-200), when needed. You may also include any sliding scale fees as part of the rate range.

Rate:

Setting: 
Generally 60 - 90 minutes.
$
/session
Generally multi-hour/multi-day.
$
/session
For Immigration cases/applications related to Waiver, VAWA, U-Visa, T-Visa, Asylum, etc.
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/day
$
/session
$
/session
$
/session
$
/session
$
/session
Generally LCDC services for clients with single diagnosis of substance use disorder.
$
/session
Generally LCDC services for clients with single diagnosis of substance use disorder.
$
/session
Generally LCDC services for clients with single diagnosis of substance use disorder.
$
/session
Generally LCDC services for clients with single diagnosis of substance use disorder.
$
/session
For clients with single diagnosis of substance use disorder (not co-occurring)
$
/session
$
/session
$
/session
In addition to the services listed above, please list additional OUTPATIENT services you offer along with rate and setting:

Service Type:

Rate:

Setting: 
$
/session

Residential Services
Please select each service you offer using the checkbox on the left. For each offered service, list the self-pay rate (not copay). For the self-pay rate, please list the unit cost in numbers only, whether it is per session or per day. You may list your rate as “0” when the service is free, or as a minimum to maximum range (e.g., 750-1100), when needed. You may also include any sliding scale fees as part of the rate range.

Rate:
$
/day
$
/day
$
/day
$
/day
$
/day
In addition to the services listed above, please list additional RESIDENTIAL services you offer along with rate and setting:

Service Type:

Rate:
$
/day

Inpatient Services
Please select each service you offer using the checkbox on the left. For each offered service, list the self-pay rate (not copay). For the self-pay rate, please list the unit cost in numbers only, whether it is per session or per day. You may list your rate as “0” when the service is free, or as a minimum to maximum range (e.g., 0-2000), when needed. You may also include any sliding scale fees as part of the rate range.

Rate:
$
/day
$
/day
$
/day
$
/day
In addition to the services listed above, please list additional INPATIENT services you offer along with rate and setting:

Service Type:

Rate:
$
/day

Support Services
Please select each service you offer using the checkbox on the left. For each offered service, list the self-pay rate (not copay) and whether the service is virtual or in person. For the self-pay rate, please list the unit cost in numbers only, whether it is per session or per day. You may list your rate as “0” when the service is free, or as a minimum to maximum range (e.g., 135-200). You may also include any sliding scale fees as part of the rate range.

Rate:

Setting: 
Phone Number:
Website:

Rate:

Setting: 
Support Groups ONLY - Please do NOT include group therapy session information here.
$
/session
$
/session

Rate:

 Setting:
Please only select if provided by DSHS-certified Peer Mental Health Specialist.
$
/session
Please only select if provided by DSHS-certified Recovery Coach
$
/session
$
/session
$
/session
In addition to the services listed above, please list additional SUPPORT services you offer along with rate and setting:

Service Type:

Rate:

Setting: 
$
/session

Crisis Services
Please select each service you offer using the checkbox on the left. For each offered service, list the self-pay rate (not copay). For the self-pay rate, please list the unit cost in numbers only, whether it is per session or per day. You may list your rate as “0” when the service is free, or as a minimum to maximum range (e.g., 500-700), when needed. You may also include any sliding scale fees as part of the rate range.

Rate:
$
/day
$
/day
$
/day
$
/day
In addition to the services listed above, please list additional CRISIS services you offer along with rate and setting:

Service Type:

Rate:
$
/day

Approaches and Specializations
This field is populated by Javascript and is used to govern skip-ifs in the connector.
ADDITIONAL INFORMATION


UPLOADS & SUBMISSION
Please upload png or jpeg.
Please upload png or jpeg.
Please upload up to 4 additional photos for your profile page to give clients a better sense of you/your practice. For best results, these photos should be sized 500 x 300 (landscape orientation).
Follow-Up Form for Individual Practitioners
After you submit this form, the individual listed above (Signer Email) will be sent a link to a follow-up form that can be sent to each individual practitioner at your organization/practice to complete. The form will be pre-filled with all of the details you have already provided here, plus include individual demographic categories to ensure prospective clients can be matched with their demographic preferences. Your individual practitioners are not required to complete this form, but it may help increase the reach of your organization/practice.
Follow-Up Forms for Individual Practitioners and Additional Locations
After you submit this form, the individual listed above (Signer Email) will receive a link to a pre-filled form that can be edited to provide location-specific details for each of your additional locations. We strongly encourage you or the appropriate site director to submit a form for each location to ensure individuals can be matched with their zip code-specific preferences.
 
You also will be sent a link to a follow-up form that can be sent to each individual practitioner at your location to complete. The form will be pre-filled with all of the details you have already provided here, plus include individual demographic categories to ensure prospective clients can be matched with their demographic preferences. Your individual practitioners are not required to complete this form, but it may help increase the reach of your organization/practice. 

Contact Information