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Therapy Application
We are so glad you have found us and are seeking out therapy through our student pilot program. Please fill out this application form for us to grant paid therapy sessions.
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Email
*
Your email
What brings you to seek out therapy through our foundation? Please provide detail (i.e. not yet found a good therapist, lack of insurance, unable to pay for therapy)
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Your answer
Have you ever seen a therapist?
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Yes
No
If you answered yes, how was your experience? If you answered no, what kept you from seeking therapy?
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Your answer
Have you ever reached out to therapists from your campus wellness center? What was your experience like?
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Your answer
Prior to starting our therapy sessions, please review our expectations:
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I agree to inform my therapist if I have to cancel or discontinue my therapy sessions. If I choose to stop altogether, I will let the Foundation know.
I agree to let the Foundation know when I have completed therapy and fill out the exit form.
Required
After your therapy sessions, would you be interested in writing a testimonial about your experience through OnMyMindFoundation? Thank you!
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Yes
No
Send me a copy of my responses.
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