This form requires full completion in order for us to determine if you qualify for the Cost-Conscious Counseling Program at The Vine Wellness Group. Please fill out all fields as completely as possible and click "submit" button at the bottom. This information is used for internal clinical purposes at The Vine Wellness Group only. Only The Vine Wellness Group Clinical Staff will have access to this information. Your responses will be kept private and secure. The information will not be used for discriminatory purposes. You can change this information in the future by notifying our office via email at help@thevinewellness.com

*NOTE: Forms will not be able to be submitted with incomplete information. Not all applicants will qualify. You will be notified of your application status within 24 business hours. If you are in an emergency, please dial 911 or seek emergency care. Do not await response regarding this application.