Request support

All information you will provide on this request form is fully confidential and will only be seen by our coordinator and shared with your support person
Your Name*

First NameLast Name
Email*

Confirmation Email
Phone Number*

Area CodePhone Number
City/State*

Street Address

Street Address Line 2

Zip Code
Are you requesting support for a child/teenager?*

YesNo
Child's age
Which best describes your situation?*

1 - I have have lost everything including friends or family2 - I have lost my home3 - I lost my job or my children have lost schooling4 - I can't cope with what has happened to my communityOther
How would you rate your mental health condition? *

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is OK
What kind of losses have you experienced as a result of the hurricane/s? (optional)
Any other information you want to share (optional)
Therapist preference:

Male therapistFemale therapistEither
How did you hear about us?*

Recommendation from a family member or a friendSocial workerBrainspotting Help websiteSocial mediaOther
Please verify that you are human*
Should be Empty: