Program Application
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-Binary
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact
Full Name/Relationship/Phone Number
Support Requested (Check all that apply)
*
Assistance with therapy sessions
Assistance with medication costs
Referral to wellness programs
Which service bests fits your current needs?
*
Trauma-Focused Therapy
Child/ Youth Therapy
Domestic Violence Counseling
Drug/Substance Abuse
Depression/Anxiety, or Anger Management
Group Therapy
Cognitive Behavioral Therapy (CBT)
Individual Therapy (General Counseling)
Therapist Preference (Optional):
Sharing this information is optional and will only be used to support your comfort and care.
Race:
Gender:
Session Format
In-Person
Virtual
Briefly explain your current needs and why you are seeking support:
Are you currently receiving therapy or counseling?
*
Yes
No
If yes, provider/organization
Are you currently prescribed medications for mental health?
*
Yes
No
If yes, please list the medications
Do you have insurance coverage?
*
Yes
No
If yes, please provide the name of your insurance carrier
What is your total monthly income (before taxes)?
(Include income you personally receive — such as work, unemployment, SSI, disability, or child support.)
File Upload
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Please upload supporting documents such as recent pay stubs, proof of income, school enrollment verification, or other documentation that helps demonstrate your need for support. All information will remain confidential and is used only to determine eligibility.
Cancel
of
Consent & Agreement
By signing below, I affirm that all information provided in this application is true and accurate to the best of my knowledge. I understand that submitting this form does not guarantee assistance but will be used to determine my eligibility for available programs and services. By submitting this form, I authorize Pave the Way to Peace, Inc. to share my information with partnering licensed therapists and mental health professionals solely for the purpose of coordinating and providing mental health services.
Signature
Date
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Month
-
Day
Year
Date
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