Community Change Assistance Application
Fill the form below completely and accurately to assess need for Community Change Assistance. *Each application is a case-by-case basis, but please note that Community Change typically has a 30 day turn around on applications*
Name:
*
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
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August
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December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
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1920
Year
Phone Number:
*
E-mail Address:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you applied for Community Change assistance in the past?
*
Yes; approved for assistance
Yes; denied assistance
No
Are you a Veteran, or First Responder (EMT/Fire/Police/Healthcare Worker)?
Veteran
First Responder
If Veteran or First Responder, what branch or service did you/are you in?
Current Employment Status
*
Full-Time
Part-Time
Unemployed
As Needed
Retired
Other
Annual Income (include all sources of income including disability)
*
Must also submit most recent W2 (if applicable)
Do you currently have health insurance?
*
Yes
No
If Yes, what health insurance(s) do you currently have?
What services are you seeking assistance for?
*
Ketamine Assisted Psychotherapy series
Ketamine Assisted Psychotherapy booster
Spravato
TMS
Vitamin Infusion
Which Mental Health location and Name of Provider, did your initial consultation?
*
Please explain what barriers to treatment you have? (examples: financial, transportation, schedule)
*
Please List 3 (three) measurable goals that you would like to achieve if approved for treatment.
Goal Number 1:
*
Goal Number 2
*
Goal Number 3
*
Would you be willing to write or record a testimony to be used by Community Change Tennessee, upon completion of therapy? (This is purely for data collection and will not be used to determine approval or denial of application)
Yes
No
Please verify that you are human
*
Submit Application
Should be Empty: