Apply — Support for the Psyche

Fill out this form to apply for therapy aid. You will be contacted by a Support for the Psyche team member if you are selected to receive funds.

Contact suppforthepysche@gmail.com for additional information.

Name

First Name

Last Name

Are you a resident of the United States?

Location

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently seeing a therapist?

Therapy experience.

What is your current annual income?

Income

How many dependents do you have?

Are you a legal guardian or caretaker?

Are you currently enrolled in school?

Are you interested in online therapy?

Is therapy covered by your health insurance?

Additional information