Apply to Be a Recipient of The Community Care Fund
Please fill out the form in full. I will contact you when funds are available and when you are next in line.
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Please list your first and last name, and if applicable what name you prefer to go by. *
What pronouns you prefer to be used when making reference to you and your care? (He/She/They/etc)} *
Email Address: *
Phone number *
Please choose what type of bodywork session best describes what you're seeking from your session.: *
How much would you like to pay for your session? (This will have no bearing on the quality of service your receive or how quickly you're offered an appointment.) *
Do you identify as/with any of the following?: *
Required
I'd like to know a little bit about what you'd like to get out of your treatments. Not only will this help me understand your needs, it will also let me know if I might be a good fit for you, or if your needs may be better met elsewhere. Some examples are: "I'm having surgery and want assistance preparing for or healing from my procedure",  "I have chronic pain", "I just need a safe space to relax and decompress" or anything else that might be relevant to you.   *
How did you hear about the Community Care Fund? *
Is there anything else you would like me to know? If not, simply type N/A. *
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