Help

    Patient Seeking Help Form

    Basic Information

    Full Name

    Date Of Birth

    Phone Number

    Email

    Address

    Income Information

    Household Income (to confirm low/moderate-income status)

    Number of People in Household

    Insurance Status

    Do you have insurance?

    Type of Insurance (if applicable)

    Mental Health Needs

    Main Concerns (Brief description of mental health concerns)

    Previous Therapy

    Specific Issues (e.g., depression, anxiety, trauma)

    Preferences

    Preferred Therapy Type

    In-person or Virtual Sessions (or both)

    Preferred Days/Times

    Emergency Contact Information

    Name

    Relationship

    Phone Number

    Consent

    Signature (Enter Your Full Name Here)

    Date