Program Application
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.
Email
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 counseling or wellness programs
Briefly explain your current needs and why you are seeking support
Are you currently receiving therapy or counseling?
Yes
No
Are you currently prescribed mental health medication?
Yes
No
Do you insurance coverage?
Yes
No
If yes, to any of the above questions provide details
File Upload
Browse Files
Drag and drop files here
Choose a file
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 the information provided is accurate to the best of my knowledge. I understand that completing this application does not guarantee assistance but will be used to determine eligibility for available programs.
Signature
Date
-
Month
-
Day
Year
Date
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