LAJ Holistic Mental Health Pilot Program

LAJ Holistic Mental Health Pilot Program

Fill out this form if you're interested in learning more about our Pilot Program.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Are you a wrongfully convicted individual?

YesNo
Are you a loved one of a wrongfully convicted individual?

YesNo
Are you a mental health professional (e.g., therapist, social worker, etc.)?

YesNo
What interests you about our Pilot Program (check all that apply)?

I am a wrongfully convicted individual seeking holistic mental health supportI am a loved one of a wrongfully convicted individual seeking to learn more about LAJ's Holistic Mental Health Pilot ProgramI am a mental health provider looking to become a trained provider for LAJ's Holistic Mental Health Pilot ProgramI am a volunteer seeking to learn how to support the Pilot ProgramOther
How did you hear about LAJ's Pilot Program?

LAJ's websiteLAJ's instagramLAJ's LinkedInReferral from current participants in LAJ's Pilot ProgramReferral from a mental health providerReferral from other organizationsOther
Additional comments or questions
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