Psychological support - Los Angeles wildfires

Free Psychological Support and Trauma Healing for those affected by the Los Angeles wildfires

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
Please confirm your email*
Name*

First NameLast Name
Phone Number*

Area codePhone Number
City/Town*
Please share with us who you are requesting support for*

SelfChild/TeenagerSpouse
Please check if you are an Emergency Responder

I am an Emergency Responder
Please select:

Law Enforcement OfficerFirefighterEmergency Medical Technician/ParamedicDispatcherMilitaryOther
Which department response are you directly connected to?

•State•County/Municipal•Federal•Volunteer•International
Please list specific department here
Please describe briefly how you have been affected*
Preferences
Therapist preference*

Male therapistFemale therapistEither
Language needs: please specify request. We will do our best to match you with a bilingual therapist/coach
Please use this space to indicate any special requests:

Preferred days and times. Please check all that apply

Free Psychological Support and Trauma Healing for those affected by the Los Angeles wildfires