DHWCares Free and Low Cost Counseling

DHWCares Free and Low Cost Counseling
Client Name*

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Email*
example@example.com
Phone Number*
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Today's Date*

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Date
Name of Provider at DHWC (if unsure or unknown, enter "NA")*
Diversified Health and Wellness Center offers free and low-cost counseling services to those who qualify through our 501(c)(3) non-profit organization, Diversified Cares. We offer a sliding scale from $0 - $50/session, or we may waive the session fee entirely based on financial need. Please note that fees for late cancellations/arrivals or missed appointments will still apply. Please check the following boxes that apply to your current financial situation:*

I currently do not have health insurance or waiting for insurance coverageI am currently in-between jobs or unemployedThe income my household brings is sparse, inconsistent, or fixed monthlyI have dependents that I am financially responsible for in my household
I certify that I qualify for free or low-cost counseling based on the following reason(s) and explanation(s) listed above.

Client or Parent/Legal Guardian Signature: Signature*
Date: Date*
Please provide any additional information that will explain your specific situation, and how we may assist you.
For Office Use
Client Fee Per Session
Provider Signature

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Date

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Date
Clinical Director Signature

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Date

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Date
Should be Empty:

For Office Use