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Request for Mental Wellness Support

Please use this form if you would like to make a request for mental health supportive services to help you as you weather the challenges of growing a business.

Building a business is stressful and can surface trauma that can block owners from personal and business growth. We know that mental health supports your business health and are pleased to offer gender and culturally competent support services through our partnership with Holistic Community Therapy, a Black-owned and queer-owned mental health occupational therapy private practice and the only practice of its kind in Oregon.

Mental health support services consist of two 50-55 minute, one-on-one consultations for small business owners to help address barriers to your business growth and success.

Topics include:
  • Managing daily tasks in the face of experiencing overwhelm, trauma, or other mental health symptoms
  • Learning short term skills to support trauma and stress reaction
  • Staying organized using technology and systems to support work
  • Improving self-image or self-esteem around running a business
  • Managing chronic health conditions and navigating medical systems to support overall well-being
  • Exploring and implementing healthy lifestyle choices to support a strong foundation for mental wellness
IF YOU ARE HAVING A MENTAL HEALTH CRISIS, PLEASE TEXT 741741 or GO TO https://namior.org/resources/in-crisis/

Support services are not considered full-spectrum counseling or therapy and are solely used to help process immediate crises, stressors, or experiences that are creating distress.

Please reach out if you have any additional questions: matea@xceleratewomen.org
Your information is confidential and is protected from public distribution.
Business Registered in Oregon*
Date of First Sale*
//
If uncertain, please estimate. If business was not operating that year, please put "0".
If uncertain, please estimate. If business was not operating that year, please put "0".
What industry/sector is your business in?*
Sales Channels*
Brick & Mortar locations include retail stores, restaurant locations, and public facing offices with regular business hours.
Please include yourself and FT/PT employees
Business_Funding_Sources
Currently Applying for Loans/Grants/Investments*
Are you working on launching new products, services, or opening new locations? *

Demographic Information

Our programs are offered on a sliding scale and are supported by public contributions. This information is used to measure your vulnerability as an entrepreneur so we may determine your eligibility for free or low cost services. This information is confidential. Xcelerate does not discriminate or tolerate discrimination based on race, color, religion, sex, origin, disability, age or genetic information.

Which communities do you identify with?*
Check all that apply.
Which communities do you identify with?*
Check all that apply.
What pronouns do you use?*
This includes you and any adult living under your roof, contributing to your monthly bills.
What languages do you speak at home?*
Check all that apply.

Acknowledgements & Additional Questions

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