Community Care Fund
If you live in Mecklenburg County, are pregnant or within two years of your baby's birth, and are unable to access needed mental health support due to cost, transportation or child care issues, please fill out the form below.
Email address *
Name *
Full Address *
Best Contact Phone Number *
Email *
Child's Birth or Due Date *
YOUR Birth Year *
Do you have insurance? *
If yes, what is your copay amount for therapy?
Please detail company or source & type of health coverage. (N/A if none) *
Do you have a therapist you wish to work with?
Do you have transportation access or virtual access to needed services? *
Please detail if answer is No or Other.
Please share any other information you feel is important that we understand.
Our support staff will reach out to you very soon to see if we can assist you in getting the care you deserve.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy