Connect to Care Application

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Whatsinthemirror? would like to thank you for applying for mental health services via our Connect to Care Program. Program funding will cover a consultation and up to 3 clinical session with one of our pre-screened therapist or a therapist of your choice, its totally up to you. In order to provide you with the best available resources we ask that you fill out the questions below.

Email *

Name *

Phone number *

Age/Date of Birth *

Gender Identity *

Preferred Pronoun *

Insurance Coverage *

Yes

Required

If you have insurance, what's the name and billing information?

Ethnicity *

African-American

Hispanic/Latino

Native American/American Indian

Asian/Pacific Islander

White

Other (Specify)

Required

Household Income *

0-16,000

16,001-30,000

30,001-47,000

47,000+

Required

County Residence *

Bastrop

Caldwell

Hays

Travis

Williamson

Other:

Required

Can we contact you via email *

Yes

Required

Send me a copy of my responses.

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