HealHaus Foundation Mental Health and Wellness Fund Application

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Enrollment is currently closed. Please sign up for our newsletter on our website to get information for when enrollment will open.

Welcome! We're happy you're here.

Please fill out the following questions so we can get to know you. All information provided here is confidential and will only be shared with a therapist if you are selected to be matched.

Please note: Our Mental Health Therapy Program signup form opens on a quarterly basis. If you're admitted into the cohort you can expect to receive a follow-up email within four to six weeks. If the form is closed when you visit, please add your email and we’ll notify you when it reopens again.

Email *

Name (First, Last) *

Age *

<18

18-24

25-34

35-44

45-54

55+

What are your preferred pronouns? *

Current Location/Timezone *

This fund prioritizes those from the BIPOC community. How do you identify? *

Black

Indigenous

Person of Color

I am not BIPOC

Prefer not to answer

Other:

Are you currently in therapy? *

Yes

Have you ever tried talk therapy? *

Yes

What do you hope to get out of therapy? Please provide as much info as you're comfortable with. This helps us to better match chosen recipients with therapists. *

How did you hear about us?

Social Media

Website

Email/Newsletter

Friend

Other:

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Send me a copy of my responses.

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