• Free Therapy Fund Application 2026

    Complete the intake questions to apply for limited free therapy support. Submitting this form does not guarantee funding. Please identify a therapist you would like to work with before applying, as Therapy Fund Foundation provides financial assistance but does not match applicants with therapists. We do have a provider directory with over 200 therapists we have personally vetted for you to choose from. This is not a crisis service. If you are in immediate danger or need urgent support, call 911 or call or text 988.

  • By moving forward with this application I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities and/or release of information must be sent to your treating provider, if desired.

    I acknowledge and give permission for any and all information associated with my registration to be used by the THERAPY FUND FOUNDATION strictly for billing, statistics and quality assurance.

    I acknowledge that service fees for special exceptions, insurance copays, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign.

  • Format: (000) 000-0000.
  • How did you hear about our fund?*
  • Are you also interested in Peer Support Services?*
  • Are you already working with a therapist?*

  • Before continuing, we recommend identifying a therapist you would like to work with. You may still submit your application, but funding cannot be approved until a therapist confirms they are able to see you.

    To search for a participating therapist, please visit our Find a Therapist directory.

  • What is your gender?*
  • Do you live or attend school in the City of Seattle? (This is NOT a requirement)*
  • What is your sexual orientation?*
  • How do you identify?*
  • Do you have insurance or EAP?
  • If you marked "NO" you do not have insurance or EAP, please tell us why?

  • If you are interested we can get you signed up for insurance. Contact admin@therapyfundfoundation.org for support.

  • Does your therapist accept your insurance?
  • Have you used THERAPY FUND in the past?
  • Are you facing a financial need preventing you from paying for therapy?*
  • Have you ever received mental health services before?
  • If so, when?
  • Please select your primary concerns.
  • Are you seeking individual or group therapy?*
  • Are you a parent/caregiver of a child under 3 years old?*

  • Adverse Childhood Experiences (ACE) Screening

  • Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you, or act in a way that made you afraid you might be physically hurt?*
  • Did a parent or other adult in the household often push, grab, slap, or throw something at you?*
  • Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way?*
  • Did you often feel that no one in your family loved you or thought you were important or special, or that your family did not look out for, feel close to, or support each other?*
  • Did you often feel that you did not have enough to eat, had to wear dirty clothes, and had no one to protect you, or that your parents were too drunk or high to care for you or take you to a doctor?*
  • Were your parents ever separated or divorced?*
  • Was your mother or stepmother often pushed, grabbed, slapped, kicked, bitten, hit, repeatedly beaten, or threatened with a gun or knife?*
  • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*
  • Was a household member depressed or mentally ill, or did a household member attempt suicide?*
  • Did a household member go to prison?*
  • Each Yes response equals 1 point. Add your Yes responses and select your total ACE score.

  • PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems?

    Please select one response for each statement.
  • PHQ-9 response grid*
    Rows
  • Your response indicates that you have recently experienced thoughts of being better off dead or hurting yourself. You deserve immediate care and support. If you are in immediate danger or believe you may act on these thoughts, call 911 or go to the nearest emergency department now. You can also call or text 988 to connect with a trained crisis counselor. Please do not wait for Therapy Fund Foundation to review your application, as applications are not monitored continuously and submitting this form is not a crisis response service.
  • PHQ-9: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

  • GAD-7: Over the last 2 weeks, how often have you been bothered by any of the following problems?

    Please select one response for each statement.
  • GAD-7 response grid*
    Rows
  • GAD-7: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
  • Your responses suggest that you may be experiencing significant symptoms of depression and/or anxiety. These questionnaires are screening tools and do not provide a diagnosis. We encourage you to speak with a licensed mental health professional or healthcare provider for a complete assessment and support. Please note that Therapy Fund Foundation applications are not monitored continuously, submitting an application does not establish a therapist-client relationship, and this application should not be used to request emergency or crisis support. If you need immediate emotional support, call or text 988 to connect with the 988 Suicide & Crisis Lifeline. If you are in immediate danger or believe you may act on thoughts of harming yourself or someone else, call 911 or go to the nearest emergency department.

  • Therapy Fund Participation Agreement

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Provider Verification Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approval Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Contact Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: