LoveMLT Application

1

Name* This field is required.

First Name

Last Name

2

Address* This field is required.Counseling Subsidization is available to those living in Mountlake Terrace or attending Mountlake Church at least 3 times monthly.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

3

Do you currently attend Mountlake Church at least three times monthly?* This field is required.Counseling Subsidization is available to those living in Mountlake Terrace or attending Mountlake Church at least 3 times monthly.

YESNO

4

Phone Number* This field is required.

5

Email* This field is required.

example@example.com

6

Date of Birth* This field is required.

Date

7

Preferred Method of Contact* This field is required.We will contact you within a week of receiving your application.

Phone

Email

8

Do you have a preference for a male or female therapist?

Female

Male

No preference

9

Have you seen a mental health professional before?

YesNo

10

Please specify previous mental health care received.* This field is required.

If yes, please specify

11

Have you ever been formally diagnosed with a mental health condition?* This field is required.

YesNo

12

Please specify any formally diagnosed mental health conditions and medications you are currently taking for these conditions:* This field is required.

13

Are you experiencing suicidal thoughts or urges to harm others?* This field is required.For mental health crisis, thoughts of suicide, or harming others we encourage you to call 911 or 988 immediately for help.

YesNo

14

What else would you like us to know?

15

What is your annual income?* This field is required.We need this information in order to provide subsidization to individuals and families that need it most.

Please provide your household's total annual income.

How many people are in your household including all adults and children?

16

Please select how much you could budget weekly towards counseling services?* This field is required.

$20-$30

$40-$50

$60-$70

Other

17

Please upload total household income documents for counseling subsidization applications. * This field is required.Please upload one of the following: -Paystubs from the last 3 months or Proof of Unemployment, -Copy of your most recent Tax Return, -3 months of Bank Statements, or -Eligibility letter from federal assistance programs such as Apple Health or Food Assistance.

Drag and drop files here

Select files to upload