Wildfire Relief Interest Form

Whether you or your family were directly affected, supported others, or are still feeling the emotional impact, our services are here for you. This includes first responders and caregiving professionals, community members, family members, and others seeking support to cope with trauma or ongoing stress. All ages are welcome and no insurance is required.

Once you complete this form, you will be directed to a link to schedule an appointment with one of our Intake Counselors who can explain our service offerings. If you do not schedule an appointment, one of our team members will reach out by phone or email.

To be eligible, you must currently reside in California. All fields marked with a (*) are required.

Name of person seeking services*

First NameLast Name

Name of parent/guardian (if applicable)

First NameLast Name

Age of person seeking services*

In what California county do you currently reside? *

Please select your county

What types of services are you interested in?*

Individual counselingSupport groupsTrainings or debriefingsOther

Who are these services for?*

First responders(e.g., firefighter, EMT)Caregiving professionals (e.g., healthcare worker, teacher)Persons displaced by the firesPersons impacted by the fires (e.g., family caregivers, lossof community or employment, difficulty coping with the trauma of the event,etc)

How would you prefer we contact you to set up your appointment?*

Phone callVoicemailEmailOther

The phone number for our Wildfire Services line is (424) 362-2935 . Please save this number to your phone, so that our call is not marked as spam.

Best time(s) to contact you

Hour Minutes

AM/PM Option

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Type of Health Insurance*

Note: Insurance is not required to access services

Private Insurance

How did you hear about our program*

I understand that once I submit this form, I will have the option to schedule an appointment with an intake counselor who will explain services, gather documentation, and schedule you with a clinician.*

YesNo

Please verify that you are human*

Get Connected: Wildfire Mental Health Services