Assistance Application Form

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

Month Day 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 Revitalist 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 *
Should be Empty:

Community Change Assistance Application

Please List 3 (three) measurable goals that you would like to achieve if approved for treatment.