Alma Gethers Therapy Fund Application

I'm applying for

Name

If this is for a boy under 18, use his first name and last initial only.

Age

Parent/Guardian Name

First NameLast Name

City

State

Email

If this is for a boy under 18, enter a parent or guardian's email.

Phone Number

If this is for a boy under 18, enter a parent or guardian's phone number.Format: (000) 000-0000.

Best way to reach you?

What would you like support with? Choose any.

Have you seen a therapist before?

What format would you like to have sessions?

Best days and times?

Anything you'd like in a provider?

Please don't include diagnoses or medical details.0/500

Which fits your situation best?

Language(s) you like sessions In?

Agreement 1

Agreement 2

Agreement 3

Agreement 4

Your privacy

What we collect your contact details; the kinds of support you're looking for; whether you've seen a therapist before (optional); your session format and times; and which situation best fits your access to care. For a boy under 18, we also collect a parent or guardian's details.

Why to decide eligibility and match you with a licensed therapist.

Who can see it only our Executive Director and our Clinical Director.

Shared with a therapist? Only if you're approved and you agree below. We share your name, contact details, session format and times, the kinds of support you chose, and any provider preferences. We don't share your answers about insurance or barriers.

Clinical records stay with your therapist. We don't ask for diagnoses, treatment notes, or medical history, and we don't receive them. Your therapist tells us only that sessions took place, so we can pay them.

Full details are in our Privacy Policy.

Our therapy fund helps support

Who is applying?

What kind of support

Access and Need

Fit

Agreements