Railyard Herbal Justice Fund Request Form

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Who is eligible?

-Those who may self-identify as meeting one of the following criteria:
Living on fixed government income (SSDI, SSI, Social Security, unemployment)
Receiving public assistance
Unemployed
Houseless
Paying 50% or more of income for housing
Are struggling to support children or other dependents
Have significant debt
Have medical expenses not covered by insurance

If you meet eligibility, please answer the following questions:

Name

Date

YYYY

Phone

Mailing Address

Which services would you like to access?

walk-in consultation (10-30 minutes) (cost to you: sliding scale $2.50-30)

2-hour consultation (cost to you: sliding scale $30-125)

1- hour follow- up consultation (cost to you: sliding scale $15-60)

herbs and/or herbal formulation (HJF will cover up to $50/month)

classes (variable, average full price is $20, discount is up to 40-100% off)

How much are you able to pay out of pocket per month?

How did you hear about this program?

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