The Village TAP Intake Form

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Please fill out the form below. The Village TAP is also an LGBTQIA+ inclusive and affirming space. If you have any questions regarding the form, please email info@thevillagepath.org. If you indicate that you are experiencing suicidal thoughts or ideation (thinking about, considering, or planning suicide), we urge you to contact the national suicide hotline: 800-273-8255. We will also check-in to ensure you are okay!

Thank you,
The Village TAP Team

Email *

First Name *

Last Name *

Phone number *

Age *

Zip Code *

Are you having suicidal thoughts? *

Yes

Are you above the age of 18? *

Yes

Do you have insurance? (This may be important for after the program.) *

Yes

Maybe

How did you hear about this service?

If you selected "Other" in the last question, tell us more!

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