Powerful Voices: Informed Consent & Application for DMHS Free Therapy for Youth  - WAITLIST
Welcome to DMHS Free Therapy & Wellness Program Application form!

**Before you proceed, you must complete a Release of Information for Powerful Voices: https://forms.gle/pEbQVB8uBDMkyAEeA** - Please type  "Powerful Voices" as organization to release information to in the Release of Information form.

Signing up for services is not a guarantee of DMHS Free Wellness services.
Our program offers a minimum 12 sessions for up to 12 months of mental health and/or wellness services. As we are partnering with other organizations, the duration may vary. Your provider will assess and determine duration and frequency of services. 

WA RESIDENTS ONLY: You must be 13 or over, or have a guardian assist with & sign this application, or have a guardian assist with & sign this application on your behalf.

If the age of consent is different in another State, please refer to state code before applying. 

If you have a specific provider you would like to be matched with, please add their name in the form below. 

DMHS Free Therapy & Wellness is intended for people who don't have health insurance and can't afford therapy. DMHS will prioritize Individuals who identify as Black, Indigenous or People of Color with who can't afford wellness services. All are welcome to sign up.

We recommend that you encourage the provider to sign up on our website and have the provider mention in the form that a client has asked them to sign up.

Once you are matched with a wellness practitioner, you must email them within 30 days or your application expires. 

Wellness Provider or Therapist, or client can terminate therapy at any point in this process.

DMHS Free Therapy is NOT an emergency service.
If there is an emergency, I will refer to the information here:   988 National Mental Health Line, or 911,King County Crisis Clinic at 206-461-3222 or 866-4CRISIS (427-2727). I can also contact non-emergency peer support  877-500-9276

After this pre-screening, DMHS will determine whether you qualify for a full application. You will be placed on the waitlist and referred to a wellness practitioner as soon as one is available. 

If you are currently working with a provider, please have them complete this form: YOUTH FOCUSED: Therapist & Wellness Practitioner Matching Form (MOU)



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First & Last Name *
Email *
Re-type Email *
What are your preferred pronouns? *
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Today's date *
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月
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日
Date of birth *
年
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月
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日
Best phone number to reach you *
Were you referred by Y-We or Powerful Voices? *
Please select the organization that referred you. If neither, select "no" or "other". 
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I have completed the Release of Information and included "Powerful Voices" as the organization for DMHS to communicate with when I signed

A referral cannot be made until this form is completed.
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https://forms.gle/pEbQVB8uBDMkyAEeA
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Would you like 2 weeks to select a Provider, or do you want DMHS to select & assign a Provider for you? *
If you are currently working with a provider, please tell is their name and email
Do you want to include your parents or guardians in the therapeutic process? *
What kind of services are you requesting? *
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How do you identify? *
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Age *
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How would you describe your gender? Feel free to check multiple!  *
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How would you describe your gender identity in your own words? 
How would you describe your sexuality? Feel free to check multiple!  *
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What language are you requesting services in? *
If your preferred language is not on this list, please select "other" and write in your preferred language. 
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What would you like to address with your wellness practitioner?  *
Select all that apply.
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Are there financial barriers preventing you or your guardian from paying for wellness services? *
Are you eligible for other services that provide social services assistance (medicare or medicaid, DSHS)? *
What services do you currently receive (if you receive any)? (optional) *
If you do not receive any of these services, select "none apply" or "other". 
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Do you have health insurance that covers mental health services?
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(If Yes) What health insurance do you have?
(If you have health insurance) Are you unable to find an available Provider of Color who accepts your health insurance?
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Have you worked with a therapist in the past? *
If "Yes", did you feel like you couldn't open up to your therapist or wellness provider due to race or racism?
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Would you be ok with being matched with a Wellness Practitioner instead of a Therapist?
(i.e.: Coaching, yoga, wellness, reiki)
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If Yes, what kind of wellness would you be interested in experiencing (e.g. yoga, sound bath, meditation, etc)
Would you be open to group therapy or group wellness ? *
Would you be ok with being matched with an Intern or Practicum Student ? *
Have you recently been in Inpatient Treatment for Youth? *
Have you recently had interactions with the Legal System, or Juvenile System? *
Do you attend school regularly? *
What state are you located in? *
If you answered Washington State, where in Washington State are you Located? *
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How did you hear about the DMHS Free Therapy program? *
必填
(Optional) Name of Therapist who I would recommend for this program/wish to work with
(Optional) If you are re-applying for services, who did you work with? 
How will DMHS Free Therapy services help you? What do you hope to accomplish through therapy? *
Terms & Conditions: 
I understand if I am approved for services, that getting matched with a provider may take time and is based on the availability of providers, and other limited resources.

I understand and acknowledge that DMHS Free Therapy is NOT an emergency service. If there is an emergency, I will refer to the information here:   988 National Mental Health Line, or 911,
King County Crisis Clinic at 206-461-3222 or 866-4CRISIS (427-2727). I can also contact non-emergency peer support  877-500-9276

I give and acknowledge permission for all of the information I provide in this form, for DMHS to use for quality improvement and statistics.

I understand & acknowledge that completing a DMHS Free Therapy application, that I am authorizing sharing my registration and its contents (referral) with my chosen or assigned provider.

I understand that once I am assigned to a Provider, I agree to their policies that include but are not limited to copays, cancellation fees.

WA RESIDENTS ONLY: I am 13 or over, or have a guardian assist with & sign this application. 

If the age of consent is different in another State, please refer to state code before applying. 
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I am signing as *
Attestation and Consent:  By signing below, I hereby consent to all of the information above in this application 
 (Please type your full name on the line)
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