PARTNER REGISTRATION FORM

ORGANIZATION INFORMATION

ORGANIZATIONAL STATUS (Check all that apply)

CONTACT INFORMATION

POPULATIONS SERVED

Please describe the primary populations your organization serves (check all that apply):

PROGRAM PARTICIPATION (Check all that apply)

MMP Community Partner (Distribute free mental health checkups in your community. Non-Clinical and organizations)

MMP Community Ambassador (Donate your time to help the Million Minds Project mission)

MMP Clinical Partner (Receive free referrals along with mental health checkup reports)

If MMP Clinical Partner, what services do you offer (check all that apply):

In-person Counseling/therapy

Telehealth Counseling/therapy

In-person Psychological services

Telehealth Psychological services

In-person Psychiatric services

Telehealth Psychiatric services

In-person Addiction services

Telehealth Addiction services

Preferred Distribution Method(s):

Online (Digital Access)

In-Person Events

Community Outreach

Other

Would you like to recommend other organizations to participate as partners?

Yes

No

COMMITMENT STATEMENT

As a participating Million Minds Project Partner, our organizations agrees to:

- Promote access to free mental health check-ups within our community.

- Maintain confidentiality and dignity for all individuals served.

- Distribute resources equitably, without discrimination or bias.

- Collaborate with Million Minds to ensure equitable distribution and outcome reporting (aggregate data only, no personal health information).

- Represent the mission that mental health is a basic human right.

- You cannot resell or recreate the assessment. The MMP assessment is copyrighted and trademarked under Clinicom Healthcare Inc

By signing below, we affirm our commitment to these values and agree to act as a trusted partner in advancing accessible, compassionate mental health care.

I AGREE