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!)
Behavioral Health Navigation Services Provider Profile Form
Nonprofit and for-profit organizations, group practices, solo practitioners, 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. For questions or concerns, please contact navigation@mhahouston.org.

INDIVIDUAL DEMOGRAPHIC INFORMATION

Information collected in this section will be used to match with client preferences.

GENERAL ORGANIZATION/PRACTICE INFORMATION



Licensing
(NOTE: Individuals and 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, and we will follow up with you at a later date.)
LOCATION INFORMATION

Hours of Operation

Open: Close:
Weekday Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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 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:  
Support Services
Please select each service you offer using the checkbox on the left. For each offered service, list the rate and available setting (virtual and/or onsite, where applicable). For the 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 range (e.g., 135-200), when needed.

Rate:

Setting: 
Phone Number:
Website:

Rate:

Setting: 
$
/session
$
/session

Rate:

 Setting:
$
/session
$
/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

Outpatient Services
Please select each service you offer using the checkbox on the left. For each offered service, list the rate and available setting (virtual and/or onsite, where applicable). For the 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 range (e.g., 135-200), when needed.

Rate:

Setting: 
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/session
$
/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 rate and available setting (virtual and/or onsite, where applicable). For the 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 range (e.g., 135-200), when needed.

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 rate and available setting (virtual and/or onsite, where applicable). For the 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 range (e.g., 135-200), when needed.

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

Crisis Services
Please select each service you offer using the checkbox on the left. For each offered service, list the rate and available setting (virtual and/or onsite, where applicable). For the 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 range (e.g., 135-200), when needed.

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.
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 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.

Since your organization has multiple locations, you 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.

Contact Information