Energize Colorado Therapy Connection Request Form
Energize Colorado is a nonprofit mobilizing generous Coloradans to provide resources and relief to small businesses, nonprofits, and individuals, supporting them in recovering from the impact of COVID-19. We've brought together mental health professionals to offer free and low-cost therapy, in an effort to make sure that anyone who needs support is able to access it.

If you are in need of free or low-cost therapy, please fill out the form below. Once you submit the form, we'll be in touch to connect you with one of our mental health partners. You can expect a reply from our team of volunteers within 2-3 business days.

If you have an urgent need or are in extreme emotional distress or thinking of ending your own life, please call 911 or contact the National Suicide Prevention Lifeline either by calling 1-800-273-8255 or through their online chat or contact the Crisis Text Line by texting HOME to 741741

This form should take roughly 10 minutes (or less) to complete. Thank you!
Email address *
Full name: *
Phone number: *
Preferred Contact Method(s) *
Required
Where in Colorado are you located? (City) *
I'd prefer to have my therapy sessions conducted in: *
Required
Which type of therapy sessions would you prefer to attend? *
if you're not comfortable with video chat or phone sessions, please select "Other" and let us know more about your needs.
Would you be interested in learning more about group therapy sessions? *
In our effort to serve Colorado's workforce, please let us know which of the following statement(s) best describe you: *
Required
Do you have insurance? *
To help us provide services to as many Coloradans as possible, if you have mental health benefits through your insurance plan or are able to afford a low-cost option, please let us know and we'll connect you with one of our providers who offers a low-cost option.
If you have insurance, what company is it with?
This information will help us identify provider(s) who are able to accept your insurance.
Do you have a connection to the military? *
This could include a family member who is active/retired military.
Do you have a preferred gender for your therapist? *
Required
Do you have a preferred race or ethnicity for your therapist?
Do you have a preferred age range for your therapist? *
Required
Is there anything else you would like us to know that could help us better connect you with a therapist?
How did you hear about us?
Once you submit this form, we'll review your information and reach out if we have any additional questions. You can expect to hear from our team of volunteers in 2-3 business days.
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