Depression Survey
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Check ONE (1) box that fits you the most...
Have You Applied Here Before?
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Have You Received Funding From Us Before?
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Do You Exercise Regularly?
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SURVEY QUESTIONS:
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Your answers help us match you with a provider
I like to spend time in outdoors/nature
I struggle with being present
I have high anxiety
I want to work on physical & mental fitness
I feel like a spiritual person
I want to expand my spiritual self
I have a weak sense of purpose
I have unhealthy addictions/fixations
I would like to work on my addiction(s)
Wellness Therapy Options
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Agreement
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By selecting "Yes" you agree to not hold Blake's Tinman (also known as Blake Matthew Mindful Memorial Foundation, Inc.) responsible or liable for any events that may result from a referral or sponsorship provided by the Blake Matthew Mindful Memorial Foundation, Inc., and you agree to the following terms and conditions:
Terms and Conditions for Wellness Grant Recipients
Effective Date: February 1, 2025
These Terms and Conditions ("Agreement") govern your participation as a Wellness Grant Recipient ("Recipient," "you," or "your") in the wellness grant program provided by Blake Matthew Mindful Memorial Foundation, Inc. ("Blake's Foundation," "we," "us," or "our"). By accepting a wellness grant from Blake's Foundation, you agree to abide by the terms set forth in this Agreement.
1. Eligibility for Wellness Grants
To be eligible for a wellness grant, you must meet the criteria set by Blake's Foundation, including but not limited to:
Demonstrating a need for mental health and wellness support.
Completing the application process and providing required information.
Participating in an onboarding interview with Blake’s Foundation to discuss your needs and suitability for the program.
Agreeing to the use of Tinman Coin vouchers for services rendered by approved Wellness Partners.
By receiving a wellness grant, you confirm that you meet the eligibility requirements outlined above.
2. Wellness Grant Benefits
As a Wellness Grant Recipient, you will receive a Tinman Coin voucher or a series of vouchers redeemable for wellness services provided by approved Blake's Foundation Wellness Partners. These services may include:
Mental health services (e.g., therapy, counseling, etc.)
Holistic wellness services (e.g., reiki, acupuncture, yoga, sound therapy, etc.)
Other mental health and wellness-related services as determined by Blake's Foundation.
The Tinman Coin vouchers are valid only for services provided by Wellness Partners listed on our official website.
3. Tinman Coin Vouchers
The Tinman Coin vouchers you receive:
Are non-transferable, non-refundable, and have no cash value.
Are redeemable only for services provided by approved Wellness Partners.
May not be exchanged, sold, or otherwise transferred, unless authorized in writing by Blake’s Foundation.
By accepting the Tinman Coin voucher(s), you agree to use them solely for the services provided by Wellness Partners, and not for any other purposes.
4. Your Responsibilities
As a recipient of a wellness grant, you agree to:
Use the Tinman Coin vouchers for the intended purpose of receiving mental health and wellness services from approved Wellness Partners.
Attend your appointments with the Wellness Partner as scheduled. If you need to reschedule or cancel an appointment, you must do so in accordance with the Wellness Partner's policies.
Report back to Blake’s Foundation on your experience with the services you receive, including whether you attended the sessions and your feedback on the service.
Participate in follow-up evaluations or check-ins to assess the progress of your wellness journey.
Work collaboratively with the Wellness Partner to ensure that the services you are receiving are in line with your needs.
Understand that it is your responsibility to follow through with the plan set by the Wellness Partner.
Failure to fulfill these responsibilities may result in the termination of your grant, and you may be ineligible for future wellness grants.
5. Confidentiality and Privacy
Blake’s Foundation is committed to protecting your privacy and the confidentiality of any personal and health-related information. By accepting a wellness grant, you agree that:
Blake’s Foundation will maintain the confidentiality of your personal and health-related information, in compliance with applicable privacy laws, including HIPAA.
Your wellness service information may be shared with the Wellness Partner solely for the purpose of verifying the services provided (e.g., dates of service, type of service, and your name).
Any recordings, such as podcast interviews or success stories, will only be published with your explicit consent.
You have the right to request access to or correction of your personal data in accordance with applicable privacy laws.
6. Service Delivery
You understand that:
All wellness services provided by Wellness Partners are subject to their availability and policies.
Wellness Partners have the right to refuse services to you if you fail to meet their requirements or policies.
You are not entitled to any services that exceed the scope of the wellness grant provided by Blake’s Foundation.
Blake’s Foundation does not guarantee specific results or outcomes from the services provided by the Wellness Partners.
7. Termination or Modification of Grant
Blake’s Foundation reserves the right to terminate or modify your wellness grant if:
You fail to comply with the terms of this Agreement.
You do not engage with the wellness services as intended, including failing to attend appointments or provide feedback as required.
You engage in behavior that is disruptive, unsafe, or otherwise inappropriate with Wellness Partners.
Blake’s Foundation determines that continuing to provide the wellness grant is not in your best interest.
In the event of termination, your eligibility for future wellness grants may be impacted.
8. Liability Waiver
Blake’s Foundation is not responsible for any harm, injury, or loss resulting from the wellness services provided by the Wellness Partners. By accepting a wellness grant, you agree to:
Waive any claims against Blake’s Foundation related to the services provided by the Wellness Partners.
Hold Blake’s Foundation harmless from any liability arising out of or related to the wellness services you receive.
You acknowledge that the wellness services provided by the Wellness Partners are voluntary, and you are fully responsible for your participation in those services.
9. Indemnification
You agree to indemnify and hold Blake’s Foundation harmless from any claims, damages, or liabilities arising from your participation in the wellness grant program, including your use of Tinman Coin vouchers and services provided by Wellness Partners.
10. Governing Law and Dispute Resolution
This Agreement shall be governed by and construed in accordance with the laws of the state of Wisconsin. Any disputes arising from this Agreement shall be resolved through good-faith negotiation. If a resolution cannot be reached, the dispute shall be submitted to mediation or binding arbitration in the state of Wisconsin.
11. Amendments
Blake’s Foundation reserves the right to modify these Terms and Conditions at any time. Any changes will be communicated to recipients, and continued participation in the wellness grant program after such changes will constitute acceptance of the revised Terms and Conditions.
12. Miscellaneous
Entire Agreement: This Agreement constitutes the entire agreement between you and Blake’s Foundation concerning your participation as a wellness grant recipient.
Severability: If any part of this Agreement is found to be invalid or unenforceable, the remainder of the Agreement shall remain in effect.
No Assignment: You may not assign or transfer your rights or obligations under this Agreement to any third party.
Messaging Opt In: You agree to receive emails, phone calls and/or SMS messages regarding your account. You may opt out at any time by emailing blakestinman@gmail.com.
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