Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have health insurance?

If one of our preferred providers does accept your health insurance, we ask that you utilize those benefits first before applying for assistance, unless you are unable to cover co-pay amounts.

Yes

No

What is the financial assistance you are seeking? *

Full assistance to cover the full amount for therapy sessions

Partial assistance (This is for those who have Insurance that is accepted by one of our preferred providers, but needs assistance with co-pay amounts)

Monthly household income *

Before taxes

$0 - $999

$1,000 - $2,400

$2,500 - $4,900

$5,000 - $7,499

$7,500 +

Do you receive any of the following public assistance?

Unemployment benefits

SNAP

Medicaid/Medicare

Housing Assistance

Other

Did You experience any of the following as a child? (Check all that apply)

Sexual Abuse (rape, incest, molestation, exploitation)

Physical Abuse

A household member with substance abuse problems

Violence between adults in the home

Neglect

Emotional Abuse

Household Member with a mental illness

I prefer not to answer

By submitting this application, you consent to our nonprofit reviewing your information to determine your eligibility for financial assistance. All information provided will be kept confidential and used solely for the purpose of supporting your access to trauma-informed care.

I agree to the terms and conditions