Client Sign-Up & Referral Form
Project H.E.A.L. aims to provide a culturally competent safe space to minority and underrepresented individuals who have been impacted by traumatic experiences or events. Project H.E.A.L. utilizes an intake personality assessment process through a holistic approach with a focus on trauma-informed care. Based on the intake assessment, an individuals will be provided with various ways to engage through our services. If you are a community organization, parole, or probation please complete the following form and include your contact information in the notes.

Please fill out the intake form to learn more about how Project H.E.A.L. can help you. 
Call 315-832-0659 if you need any assistance!
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Email *
Name *
Phone number *
Client/Guardian Email *
If under 18, please provide a name and phone number of the parent or guardian
Address
Date of Birth *
Please check if you currently need the following
Please let us know how we can help you? *
We offer the following FREE program and services. Please choose which services you would you be interested in learning more about any of the following: *
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Comments/Notes for Project HEAL Team
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