Legacy Wellness Services Waitlist
Legacy Wellness Services serves Black women in need of quality care. We have traditionally focused on mental health services and we are looking to branch out due to the lack of quality services available to our community. Our plan is to offer services in every state. We look forward to providing services to help with your mental, emotional, physical, spiritual, and financial wellness. 

**Please note that entering this information does not form a therapeutic relationship with a therapist or coach.
Sign in to Google to save your progress. Learn more
Email *
What is your first and last name? *
What are your pronouns? *
Are you interested in mental health therapy and/or coaching? *
Required
What concerns do you need support with? (Please check all that apply even if you have not been officially diagnosed by a therapist/doctor.) *
Required
What state or country do you reside in? *
Required
Is there a particular type of therapy treatment you are looking for like EMDR, CBT, IFS, etc.? (It's okay if you are unfamiliar with therapy treatment modalities.)
May we contact you by phone? *
If you checked "yes" to contacting you by phone, what is your phone number?
Are you willing to pay out of pocket and/or use vouchers from Loveland Foundation and/or Black Girls Smile? (Sliding scale available) *
What are you looking for in a therapist/coach?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms