Provider Intake Form
Are you a professional providing mental health services to individuals and want to be listed in our resource directory? Please fill out the form below to join the 72 AND YOU community. We will be providing this FREE list of professionals to those we serve in your area of expertise. During the Beta Phase of this program the listings will be free to professionals. We hope to continue to provide this valuable list service for free through our generous partners and supports. Thanks for being part of our efforts to eliminate the barriers and access to mental health services.
Hello <Name of Therapist>,
I am contacting you and your organization to see if you would be interested in having your organization listed on 72andYou.org.
My name is Matt White and I have started 72andYou in honor of my son Joshua White. Joshua passed away in April of 2019 hiking Picacho Peak. He did not pass away from anxiety and depression, but he did live his life dealing with both. I created 72andYou as a resource for young people to get therapy, find transportation to therapy, or possible financial assistance with both.
As a football player, Joshua wore number 72. This has tremendous meaning to my family, which is why 72 is in the name of this organization. In addition, I want young people to know that they are wanted, known and seen, even though they might feel the opposite. Joshua was all about relationship. Hence the name 72andYou. You are not alone.
We hear almost daily now about celebrities and athletes coming forward describing their lives with anxiety and/or depression. None of these stories have ever described an organization willing to do what 72andYou is proposing. I would like to work with your organization to connect young people in desperate need of mental health care to quality therapeutic providers like yourself and your organization through the 72andYou website.
To compensate your organization for the initial intake session, 72andYou would like to cover the cost up to $125. Further individual and/or family therapy sessions will be covered to the cost of $100 per session.
Along with accepting new clients from 72andYou, we are looking to create educational opportunities for you and your team members to continue your growth and experience within your specific fields of practice. We want to create an environment of growth, education and collaboration between the general community and the mental health world.
If you align with the 72andYou mission and are comfortable with these suggested rates, please reply and we will send you a Therapist Organization Agreement Form.
We look forward to creating a relationship with you and your organization.
Sincerely,
Matt White
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