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.
- Name
  
  First NameLast Name
- Email Address
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Are you older than 16?
- Are you a resident of Alabama?
- Please indicate your race/ethnicity (you can choose more than one):
  
  Other
- Do you have health insurance or are you covered by an Employee Assistance Program?
- If you selected "yes", does this cover mental health care?
- 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?
- Are you:
- Why are you seeking treatment? Include when the problem started.
- How long has this problem been present?
- How does this effect your daily life?
- Have you ever received mental health therapy?
- Did you select "yes'? If so, what type of therapy did you receive?
- If you have received therapy, what worked? What didn't work?
- Check any issues you’ve faced:
- We are currently piloting a program in partnership with A Touch of Peace Counseling Services to provide our applicants with counseling from a Master's Level Intern. These interns have completed the required coursework to become licensed mental health professionals and are now gaining the final hours of supervised experience. Are you open to working with a Master's Level Intern?
- How did you hear about us?
- Would you like to be added to our group chat?
- Signature
- Should be Empty: