Tula Therapeutic Collective Application

Tula Therapeutic Collective Application

Estimated time to complete: 5-10 minutes
Welcome to Tula

Hello and welcome! Tula is a sliding-scale psychotherapy clinic for children and adults in Butte County. This questionnaire will help us to determine if our Clinic is a good fit for you, and also will serve as your registration. Once complete, you will receive a call or email from us as soon as we are able to set you up with your first appointment.
Please select the option that best describes your relationship to this application*

Your Information

Information for the person completing this form on behalf of a client or dependent.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender Identity & Pronouns*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code

FINANCIAL INFORMATION

Please fill out this section in detail. If you are completing this form on behalf of a dependent or client, please complete the information as it relates to them. You can write "0" if a certain field does not apply to you (e.g. childcare expenses). Your responses will help us understand your financial situation and determine your eligibility for this service.
Do you have insurance? Please select the best description of your situation.*
How many family members contribute to your household's income? This could include yourself, spouses/partners, parents, grandparents, children, etc.*
How many family members are supported by your household's income? This could include yourself, spouses/partners, parents, grandparents, children, etc.*
What is your annual household income?*
Are you and/or your dependent currently enrolled in any of the following programs?

School-based counselingSNAP BenefitsWICSSI/SSDISection 8Other

Agreement

Please carefully review the following before submitting your application. All clauses must apply in order to qualify for the scholarship fund. If you are submitting on behalf of a dependent or client.
I agree*

I am/ they are experiencing significant emotional and/or psychological distress and require therapeutic help at this time.
I agree*

I/They cannot afford current market rates of psychotherapy ($100-250 per session).
I agree*

I/They agree to pay between $35-$75 per session for counseling as well as the one-time $45 intake fee.
I agree*

I/They agree to inform my therapist if my financial status changes and I/They can afford sessions without aid, so that another community member can join the clinic.
Electronic Signature

By signing here, I agree that the above is true and that I am in agreement with all of the above clauses.
Signature*

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Welcome to Tula