Agave Center for Justice in Mental Health

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Fill out this quick form in order to begin the process of applying for financial assistance. You will be contacted by someone on our selection committee who will provide you with additional information about our application process. If this is an emergency, please call 988 or go to your nearest hospital emergency department.

Email *

Are you applying for yourself or someone else? *

Myself

My client

My child or dependent

Other:

Name (of client) *

Date of birth (of client) *

YYYY

Pronouns (of client)

If applying on behalf of someone else, what is your name?

What kind of assistance are you applying for? *

Individual Therapy

Couples or Family Therapy

Psychiatric Medication

Transportation

Specialty Treatment (e.g., EMDR, ketamine infusions, etc.)

Supportive Service (e.g., yoga, meditation class, energy work, etc.)

Other:

Tell us about why you need financial assistance. Include specifics about what you need, why you need help paying for it, and what barriers you have faced in trying to get what you need. (If applying on behalf of someone else, please answer this question related to why the client needs assistance and what they have faced trying to meet this need.) *

What do you think the impact would be of you (or the client) receiving financial assistance? What would happen if you (or the client) did not receive financial assistance? *

What have you (or the client) already done to try to meet this need (e.g., asked for sliding scale/reduced rate, applied for assistance at another organization, etc.)? *

What is the estimated cost of the need? Is this a one time amount or an ongoing expense? (Maximum per application = $1,500) *

Have you (or the client) had the type of service you are requesting assistance for before? *

Yes

Other:

If you answered yes above, how did you (or the client) pay for it?

Do you already have a service provider in mind?

Yes

Maybe

Clear selection

If you answered yes or maybe to the question above, who is the service provider and what is their contact information? (By providing this information, I understand that someone from ACJMH will contact my provider on my behalf to try to initiate a partnership.)

What is your (or the client's) race and/or ethnicity? *

What is your (or the client's) gender? *

Are you (or the client) part of the LGBTQ+ community? *

Yes

Unsure

Prefer not to say

Other:

Client (or guardian) Email Address *

Client (or guardian) Phone Number *

Client Zip Code *

I understand that someone from the selection committee will contact me to gain additional information about my application. I understand that the information gathered here and in the second step of the application process may be shared amongst the selection committee and board members in order to make a decision about my application.
*

I agree.

I understand that if I do not respond to the request for additional information within two weeks, my application will be discarded. I may apply again at any time.
*

I agree.

I understand that if I am applying on behalf of a client, the client must respond to our requests for further information within two weeks in order to process the application.

I agree.

Clear selection

I understand that Agave Center for Justice in Mental Health does not employ, endorse, or screen any service providers. ACJMH may provide options of existing therapist partners or therapists who have availability to work with me, but I am responsible to find a service provider that is a good fit for my needs.
*

I agree.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Agave Center for Justice in Mental Health.

Does this form look suspicious? Report

Forms