Case Management Support

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Thank you for reaching out to Project HEAL. If you're looking for help with your application for Treatment Access or you're interested in limited case management support, you've come to the right place.

Please fill out the form below with your contact information and a few details about the kind of support you're looking for. After you submit the form, our Case Management Intern will follow up with you via email to offer personalized assistance and next steps.

You're not alone, and we're here to help.

Full Legal Name *

Chosen Name *

Pronouns *

She/her

He/him

They/them

Prefer Not To Say

Name Only

Other:

Required

Home Address *

This information will help us to find relevant resources near you.

City *

State *

Email Address *

Phone Number *

How would you prefer to be contacted? *

Please select all that apply.

Phone Call

Required

Date of Birth *

Age *

Gender Identity *

Cisgender woman

Cisgender man

Transgender woman

Transgender man

Non-binary

Other

Questioning

Prefer Not To Say

Required

Sexual Orientation *

Straight

Gay

Lesbian

Bisexual

Queer

Pansexual

Asexual

Questioning

Prefer Not To Say

Other

Required

Racial Identity *

Native, Indigenous, or First Nations

Arab or Middle Eastern

East, Southeast, or South Asian

Black or African American

White

Pacific Islander

Latine, Latinx, Latina/Latino, or Hispanic

Unsure

Prefer Not To Say

Other

Required

Do you identify as disabled or neurodivergent? *

Yes

Unsure

What type of health insurance do you currently have?
*

I do not have insurance

A large group private plan provided by an employer with 50+ employees. I have this plan through my own employer or the employer of my spouse or parent

An Affordable Care Act (ACA) Marketplace plan provided by an employer with under 50 employees. I have this plan through my own employer or the employer of my spouse or parent

Medicaid for low income individuals or families

Medicare for senior citizens or people living with disabilities.

TriCare or CHAMPVA

Indian Health Service plans for Native Americans

School-provided coverage

Other:

What is the name of your primary health insurance company? *

How were you referred to Case Management support?

How did you hear about Project HEAL?

I found the application support option on the website.

I was sent from Clinical Assessment.

I was sent from the Treatment Access application process.

A Project HEAL staff member referred me.

Other:

Clear selection

What type of support are you seeking?

I need support in filling out the Treatment Access application.

I need help understand Project HEAL's programs and what would be the best fit for me.

I need assistance finding other resources -- food access, housing support, government benefits -- in my area.

I am looking for a clinical assessment.

Briefly explain, in your own words, what you would like to get out of a Case Management call/email.

Please provide an emergency contact name and phone number (only to be used if there is an emergency during our communication).

If you do not have an emergency contact, please write "no contact" and review the following question.

If you do not have an emergency contact, Project HEAL has a partnership with the Crisis Textline. If you are experiencing a mental health crisis, you can text HEALING to 741741 to be connected to a crisis counselor. Do you consent to Project HEAL connecting you to the Crisis Textline during your assessment through text or webpage if needed?

Yes

Clear selection

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