Mental Health Provider Application

There are over 16,000 untested/unsubmitted sexual assault kits (in other words, 16,000 survivors) in the state of North Carolina that are currently being tested as mandated by the Attorney General in 2017. Being notified by law enforcement and/or advocates years, sometimes decades later, that their sexual assault kit has been tested, can understandably cause trauma to a survivor and their loved ones. The North Carolina Department of Justice is pleased to provide them the possibility of free counseling services via our Survivor Fund, which is funded through our federal DOJ SAKI Grant. Having to pay for these services out of pocket or through their own insurance is a burden that no survivor should have to endure. We invite you to help us provide this trauma-informed service by applying to be a 3rd party service provider. Once approved, you will need to submit monthly invoices and the NC DOJ will reimburse you the full amount requested within the maximum amounts listed below.

Mental Health Evaluation & Treatment Plan

To be completed and signed by a licensed therapist or licensed supervisor. Interns are not eligible providers.

Questions with a red asterisk (*) are required
Client Information
Client Code * Required
If you do not know your client code, please contact Cynthia Clark, SAKI Victim Advocate, (919) 716-6517
Is the client a primary or secondary victim? * Required
Is it your professional opinion that upon notification of test results from their sexual assault kit which had previously been untested, this client has experienced re-traumatization? * Required
Is it your professional opinion that mental health services can address this impact of re-traumatization and improve this client’s mental well-being? * Required
What is your estimated plan of treatment for this client as it relates to the type of mental health service, frequency and duration? * Required
Please describe in detail your professional experience as it relates to working with survivors of sexual trauma. Please include any professional training in your description. * Required
Mental Health Provider Information

Please provide the following information for the mental health provider (MHP) performing treatment
Full Name of MHP * Required
First Middle Last
MHP Credentials * Required
Agency * Required
Mailing Address * Required
Street Address Address Line 2 City State ZIP Code
Email * Required
Phone Number * Required
Describe your professional philosophy around working with survivors of sexual trauma: * Required
NC Professional License Number * Required
Federal Tax ID or Social Security Number of Provider * Required
* Required
I understand that I am responsible for submitting invoices for reimbursement to NC DOJ after services are provided to the applicant. This can be monthly.
a. Up to $200 per session for individual and family therapy performed by a licensed psychiatrist and up to $100 per session for group therapy. b. Up to $150 per session for individual and family therapy performed by a licensed psychologist or a licensed PhD level therapist and up to $75 per session for group therapy c. Up to $120 per session for individual and family therapy performed by a licensed master's level therapist for Advanced Practice Registered Nurse and up to $50 per session for group therapy. * Required
I understand that the following maximum amounts are allowable for mental health services:
a. Up to $200 per session for individual and family therapy performed by a licensed psychiatrist and up to $100 per session for group therapy.
b. Up to $150 per session for individual and family therapy performed by a licensed psychologist or a licensed PhD level therapist and up to $75 per session for group therapy
c. Up to $120 per session for individual and family therapy performed by a licensed master's level therapist for Advanced Practice Registered Nurse and up to $50 per session for group therapy.
NOTE: If MHP is "registered" with and/or has a temporary license but is not fully licensed with the State of North Carolina, the full name and signature of the licensed supervisor must be provided. Student interns are not eligible providers.
Signature of MHP Providing Treatment * Required
Date * Required
MM slash DD slash YYYY
Signature of Licensed Supervisor (If Necessary)
Name of Licensed Supervisor (If Necessary)
First Middle Last
Date
MM slash DD slash YYYY
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Contact

For questions related to the Survivor Fund Applications and for survivor support, please contact Cynthia Clark, SAKI Victim Advocate, at survivorfund@ncdoj.gov or (919) 716-6517.

For questions about invoices and billing, please contact Juliette Grimmett at jgrimmett@ncdoj.gov or (919) 624-9575. Please note, all invoices should be emailed to Juliette Grimmett

Mental Health Provider Application

Mental Health Evaluation & Treatment Plan

Client Information

Mental Health Provider Information

Contact