Low Fee Program Form Name * First Name Last Name Email * Phone * (###) ### #### Type of therapy needed * Which type of therapy are you interested in? Individual therapy Family therapy Couples therapy Unsure How do you qualify? * Eligibility requirements for the program Student Loss of job Economic hardship Other If you chose Economic hardship or Other in the previous question, please explain why to qualify. Availability * When are you normally free for an appointment? Choose all that apply. Flexible Weekdays Weekends Evenings Have you seen a therapist before? * Yes No If we currently have a waitlist, would you like to be added to it? * Yes No Our intake coordinator will contact you within 24 hours with more details. Thank you for your inquiry, we look forward to serving you.
