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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

  • If you do not know your client code, please contact Cynthia Clark, SAKI Victim Advocate, (919) 716-6517
  • Mental Health Provider Information

    Please provide the following information for the mental health provider (MHP) performing treatment

  • 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.

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

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