The Jump Start-Mental Health Therapy Registration

The Jump Start-Mental Health Therapy Registration

Please fill out this form carefully.If you’re selected, we’ll contact you by email or phone. If we can’t select you right away, you’ll go on our waiting list and we’ll notify you when a spot opens.
By submitting this form, you give permission for your therapist to send billing claims to 57 North Hampton.

NO OTHER INFORMATION WILL BE SHARED WITH US WITHOUT YOUR CONSENT.

*If you haven't heard from us within a week, please check your spam folder.

INSURANCE
Do you have health insurance or are you covered by an Employee Assistance Program?*

YesNo
If you selected "yes", does this cover mental health care?*

YesNoI do not have health insurance and am not covered by an Employee Assistance Program

MENTAL HEALTH HISTORY
If you do have insurance that covers mental health care, why have you chosen to apply to join The Jumpstart? (provide as much detail as possible) *
What's been the biggest obstacle you've faced in receiving mental health care?*