AHM Pro-Bono Therapy Application
Our pro-bono therapy program provides short term financial assistance to eligible recipients. If selected, the recipient will be eligible for temporary financial relief in the form of up to 12 therapy sessions (a value of $2,100) at no cost. This program is funded by our company internally as a public service and contribution to our loving community.
Eligibility criteria:
18 years or older
Currently experiencing financial hardship
Physically located in California at time of sessions
Open to teletherapy (due to COVID-19 restrictions)
Not a personal friend or relative of the therapist providing services
Not currently involved in any legal proceedings requiring therapist participation/assessment
Once you complete an application, you will be entered into a pool of applicants. When a Pro-Bono slot becomes available, a lottery will occur and an applicant will be selected at random. Once selected, an AHM team member will reach out directly to the applicant to be offered the slot. The selected applicant will not be announced publicly due to privacy concerns. The selected applicant has 72 hours to contact back and accept the slot or it may be relinquished. If for any reason the applicant is unable to utilize the slot, another drawing will occur.
* Required
Email address
*
Your email
First Name
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Your answer
Last Name
*
Your answer
What is a good contact phone number for you?
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Your answer
Are you currently experiencing financial hardship? Please briefly describe your need for financial assistance.
*
Your answer
Are you over the age of 18?
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Yes
No
Are you currently physically located in California?
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Yes
No
Are you open to teletherapy (due to COVID-19 restrictions)?
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Yes
No
Are you a personal friend or relative of the therapist providing services?
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Yes
No
Are you currently involved in any legal proceedings requiring therapist participation/assessment?
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Yes
No
Would you like to subscribe to our email list for future offers, options, events, and mental health resources?
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Yes
No
Would you like to be contacted regarding alternative counseling options and resources?
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Yes, Please.
No, Thank you.
By completing this application, I am confirming that the above information is complete and correct. I understand that this application is not a guarantee of services. I understand providing false or inaccurate information may result in disqualification from this program.
*
I agree and confirm the above information provided is correct.
Required
A copy of your responses will be emailed to the address you provided.
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