Reclaim Foundation Therapy Assistance Program
The Therapy Assistance Program by Reclaim Foundation provides therapy assistance to survivors of trauma that need financial assistance.

Selected participants will receive assistance to find a therapist in their area and, if applicable, one that is in their insurance-coverage; If the participant does not already have one. Once the participant has found a therapist, Reclaim Foundation will reimburse the participant the cost of up to 6 therapy sessions (at less than or equal to $150 per session). The participant must provide a receipt to Reclaim Foundation in order to be reimbursed for the therapy session or, if permitted by the therapist, Reclaim Foundation can be billed directly.

Previously selected applicants may reapply after their 6 sessions have been covered, although no special preference is offered to returning applicants.

Applicants are selected for the therapy program on a rolling first-come first-served basis when funding is available. If you are selected, we will contact you via email (hi@reclaimfoundation.org) with next steps. Due to limited funding, we may be unable to provide services to all that apply. If you are not contacted, please note that we will keep your information on file and may be able to contact you to provide services once the funding becomes available.

If you are in immediate distress, please call 911 or 988, the Suicide and Crisis Lifeline. Alternatively, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) at 1-800-985-5990 for 24/7 confidential support.

About Reclaim Foundation:
Reclaim Foundation is an entirely volunteer run and operated California 501(c)(3) non-profit organization. Reclaim Foundation assists in raising awareness, creating resources, and all around supporting anyone impacted by any kind of trauma. Some of the types of trauma we are actively working towards supporting are those affected by gun violence/mass shootings, vehicle related trauma, cancer, natural disasters (including wildfires), and more.

www.reclaimfoundation.org
@ReclaimFndn

Todays Date *
MM
/
DD
/
YYYY
Last Name, First Name *
Email Address *
Phone Number (xxx)xxx-xxxx *
Birthday (month, day, year) [Must be 18 years old or older to apply] *
MM
/
DD
/
YYYY
Residential Address [Must be a California resident to apply] *
Have you or a family member ever served as a volunteer or in any other capacity for Reclaim Foundation previously? *
If so, please confirm the capacity in which you or your family member were/are involved with Reclaim Foundation - Select all that apply. *Some selections may exclude you from being eligible for the Therapy Program. Reclaim Foundation may contact you for additional information.*
Do you identify as a trauma survivor? *
What is your household income? *
What language would you prefer your therapy sessions be conducted in? *
Are you currently seeing or have you previously seen a therapist? *
Have you previously been selected to receive assistance from Reclaim Foundation through the Therapy Assistance Program ? *
Please use this space to elaborate on the reasons you are choosing to seek therapy and applying for the Reclaim Foundation Therapy Program.
I hereby confirm that all of the information I have provided in this application is true, complete and accurate to the best of my knowledge. *
Required
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Reclaim Foundation. Report Abuse
Google Forms