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Connect to Care Application
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 2 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 *
Required
If you have insurance, what's the name and billing information?
Ethnicity *
Required
Household Income *
Required
County Residence *
Required
Can we contact you via email *
Required
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