Request for Services

Request for Services

Please fill out the form below if you are interested in no-cost services provided by The Wellness Coalition. All information collected is confidential. If you would like to speak to someone on the phone, please call 334-293-6502.
Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number

Area CodePhone Number
Alternative Phone Number (if available)

Area CodePhone Number
Email Address (if available)
Example: johndoe@gmail.com
What type of health insurance do you have?
What type of chronic disease(s) do you have? (select all that apply)
What services are you interested in?

Other
How did you hear about The Wellness Coalition?

Other
If another agency/organization referred you, please tell us the name of the agency.
Please provide additional information that will help us better assist you.
PLEASE CONTACT ME ABOUT SERVICES PROVIDED BY THE WELLNESS COALITION. I UNDERSTAND THAT THERE IS NO OBLIGATION TO USE THESE SERVICES AND THAT THERE IS NO COST FOR THESE SERVICES.
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