Financial Assistance Application

Full Name *

Email *

Phone *

City *

State *

Date of Birth *

Marital Status *

Single

Married

Divorced

Widowed

Do you have any children? *

0

1-2

3-4

5+

Household Size *

Gender *

Male

Female

Non-Binary

Prefer Not To Say

Which of the following best describes you? *

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

Other

Are you a Veteran? *

Yes

No

Are you a First Responder? *

Yes

No

Do you identify as a member of the LGBTQIA2S+ community? *

Yes

No

Prefer Not To Say

Financial Situation

Current Employment Status *

Full-Time

Part-Time

Unemployed

Employer *

Job Title *

Annual Income *

Please Upload Your Most Recent Paystub *

Household Income *

Please Upload Your Spouse/Co-Habitant's Most Recent Paystub

Are you currently enrolled somewhere as a student? *

Yes

No

School Name *

Do you have any major expenses to be taken into consideration, such as student loans or medical debt? If so, please explain. *

Please share a few sentences about your current financial situation and why you are seeking support. *

Therapist / Clinic

Therapist / Clinic Name where you will receive treatment *

Misc.

Have you ever been diagnosed with the following? Select all that apply. *

Depression
Anxiety
PTSD
Other
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List is empty.

If other, please name the diagnosis.

Are you willing to provide a testimonial after your treatment? *

Yes - video and written

Yes - video only

Yes - written only

No

Do you agree to fill out basic symptom assessments before and after treatment? *

I agree

Captcha