what we should call you *

you can give a fake one if that feels safer to you

First Name

Last Name

do you currently have access to other suitable mental health support (such as health insurance, work or private counseling)

yes

no

Is mental health care financially feasible for you at this time?

yes

no

*

are you black, brown or indigenous? (priority will be given to these folks, but we are planning on serving everyone who cannot afford or find care elsewhere. So far there is plenty to go around.)

yes

no