First Time Therapy Application

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First Time Therapy Application

This application is for men seeking subsidized mental health care from Men's Health Archive. Please fill out the form below and we will get back to you shortly!

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* Indicates required question

First Name *

Your answer

Last Name *

Your answer

Email *

Your answer

Phone Number *

Your answer

Zip Code *

Your answer

What is your age range? *

18-24

25-34

35-44

45-54

55-64

65-74

75+

Do you have health insurance? *

Yes

No

If yes, does your health insurance cover mental health treatment? *

Yes

No

Have you ever received mental health treatment in the past? *

Yes

No

Are you interested in receiving professional treatment in the future? *

Yes

No

Maybe

Submit

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