Have You Applied For Partnership Here Before?
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Provider Name
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Your Qualifications
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Please describe your qualifications and experience
References
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Please list three references for each type of service you provide if you do not have proof of certification. At least one reference is required for all Partner applicants.
How Do You Help With Mental Wellness?
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Choose all that apply to your services
Agreement
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By selecting "Yes" you agree to the following Terms and Conditions in place for Blake's Tinman (also known as Blake Matthew Mindful Memorial Foundation, Inc.):
Terms and Conditions for Wellness Partners - Effective Date: February 1, 2025
These Terms and Conditions ("Agreement") govern the relationship between you, as a Wellness Partner ("Partner," "you," or "your"), and Blake Matthew Mindful Memorial Foundation, Inc. ("Blake's Foundation," "we," "us," or "our"). By agreeing to partner with Blake's Foundation, you accept and agree to comply with these Terms and Conditions.
1. Partner Relationship
Blake's Foundation engages Partners to provide mental health and wellness services to grant recipients of Blake’s Foundation. Partners include both conventional and holistic service providers who meet Blake's Foundation’s qualifications and criteria.
By becoming a Partner, you acknowledge that you are not an employee of Blake's Foundation but an independent provider who has been approved to render services under the terms of this agreement.
2. Approved Wellness Services
As a Partner, you agree to provide the following services to grant recipients using Tinman Coin vouchers issued by Blake’s Foundation:
Mental health services (including counseling, therapy, etc.)
Wellness services (including holistic therapies like yoga, reiki, acupuncture, etc.)
Other services related to mental health and wellness as approved by Blake's Foundation
You agree that the services provided will align with the mission and goals of Blake’s Foundation, which focuses on improving mental health and wellness.
3. Tinman Coin Vouchers
Tinman Coin vouchers are non-transferable and have no cash value. As a Partner, you agree to:
Accept Tinman Coin vouchers for services provided to Blake’s Foundation grant recipients.
Provide services only to recipients who present a valid Tinman Coin voucher.
Submit your payment request(s) via our online Partner Portal.
Ensure that the services rendered are consistent with the service described in your partnership agreement with Blake’s Foundation.
Tinman Coins cannot be exchanged, sold, or refunded for cash and may only be used for services directly related to mental health and wellness treatments.
4. Payment and Reimbursement
Blake's Foundation does not prepay for services performed with a valid Tinman Coin Voucher.
Blake’s Foundation does not pay for services performed Instead, the Tinman Coin vouchers serve as a form of reimbursement for services rendered. By accepting a Tinman Coin voucher, you agree to provide the agreed-upon service to the recipient, and you acknowledge that:
You will not charge recipients or other parties directly for services covered by Tinman Coin vouchers.
If you require additional information or clarification regarding the voucher redemption process, you will contact Blake’s Foundation directly.
5. Qualifications and Compliance
As a Partner, you must:
Maintain the appropriate licenses, certifications, and qualifications required to provide services in your area of expertise.
Adhere to all relevant laws, regulations, and professional standards applicable to your services.
Ensure that your services are provided ethically, with care, and in a manner consistent with the principles and values of Blake’s Foundation.
Agree to not engage with Tinman Coin Voucher holders in the discussion of your opinions related to the services provided by other Wellness Partners in the Blake’s Foundation network if you are not qualified and/or licensed yourself in that particular field of work.
Encourage Tinman Coin Voucher holders to seek out other types of therapy or treatment within the network of Blake’s Foundation if they feel stuck in their journey towards accomplishing their wellness goals.
Agree to not advertise services of which you have not been professionally trained, including practices which may be misleading, without proof of training. As an example, you must agree to not advertise breathwork services if you have not been formally trained with proof by a professional certificate and three client references for that specific service.
Blake’s Foundation reserves the right to review and audit your qualifications, credentials, and practices at any time to ensure compliance with our standards.
6. Confidentiality and Data Protection
You agree to maintain the confidentiality of all personal and health-related information shared by recipients of services through Blake’s Foundation. Specifically, you will:
Handle all personal information, including PHI (protected health information), in accordance with applicable privacy laws, including HIPAA.
Ensure that no personal information is disclosed to unauthorized third parties.
Use personal information solely for the purpose of providing services to grant recipients and not for any other purpose.
You acknowledge that Blake’s Foundation takes data protection seriously and expect all Partners to do the same.
7. Termination of Partnership
Either party may terminate this Agreement with written notice to the other party. Blake’s Foundation reserves the right to terminate your partnership for any reason, including but not limited to:
Failure to comply with these Terms and Conditions.
Failure to maintain required certifications, qualifications, or licensure.
Failure to provide services in accordance with Blake’s Foundation’s standards or mission.
Misuse or abuse of Tinman Coin vouchers or other unethical conduct.
Upon termination, you will no longer be authorized to accept Tinman Coin vouchers or provide services to Blake’s Foundation grant recipients.
8. Indemnification
You agree to indemnify and hold Blake’s Foundation harmless from any claims, damages, or liabilities arising from your services, including any claims related to the quality, legality, or appropriateness of the services provided. This includes any third-party claims arising from your failure to comply with applicable laws or professional standards.
9. Liability and Dispute Resolution
Blake’s Foundation is not responsible for any personal injury, loss, or damage caused by your services. You agree to hold Blake’s Foundation harmless for any legal or financial obligations arising from the services provided under this Agreement.
Any disputes between you and Blake’s Foundation will be resolved through good-faith negotiation. If a resolution cannot be reached, the dispute will be submitted to mediation or binding arbitration in the state of Wisconsin.
10. Amendments
Blake’s Foundation reserves the right to amend these Terms and Conditions at any time. Any amendments will be communicated to Partners, and continued participation in the program after such amendments will constitute acceptance of the revised Terms.
11. Miscellaneous
Governing Law: This Agreement is governed by the laws of the state of Wisconsin.
Independent Contractors: Partners are independent contractors and are not employees of Blake’s Foundation.
Entire Agreement: This Agreement constitutes the entire agreement between you and Blake’s Foundation regarding the provision of services as a Wellness Partner and supersedes all prior agreements or understandings.
Contact Information
If you have any questions or need further clarification on these Terms and Conditions, please contact Blake’s Foundation at:
Blake Matthew Mindful Memorial Foundation, Inc.
info@blakestinman.com
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