IDG Wellness Program Interest Form

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Please fill out this form if you are interested in our weekly discussion circles, classes, or free individual, couple, and family counseling. We will follow up with you by phone within the week to talk about what you're interested in! If you need immediate assistance call the NYC Well Mental Health Hotline at 1-888-692-9355 or dial 911.

What IDG Wellness programs are you interested in? *

Free individual, couple, or family counseling

Help accessing benefits: SNAP/EBT/Food Stamps, healthcare, etc.

Talking to the Wellness Team to explore options

Other:

Required

First Name: *

Last Name: *

Phone Number: *

Email: *

ZIP Code *

Preferred Language: *

What is your TLC license number? *

How do you prefer us to contact you? *

Phone

Either phone or email

Option 4

Is there anything else you'd like us to know?

Submit

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