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Individual Therapy Scholarship Application
If you or someone you know needs immediate assistance:
Call the NAMI HelpLine at available Monday through Friday, 9am-5pm, CST at 800-950-6264
IN AN EMERGENCY
If you or someone you know is in immediate danger, calling 911 and talking with police may be necessary. It is important to notify the operator that is a psychiatric emergency and ask for an officer trained in crisis intervention or trained to assist people experiencing a psychiatric emergency.
IN A CRISIS
National Suicide Prevention Lifeline - Call 800-273-TALK (8255)
The Trevor Project - Crisis Intervention and Suicide Prevention for LGBTQ Youth - Call 866-488-7386
National Sexual Assault Hotline - Call 800-656-HOPE (4673)
National Domestic Violence Hotline - Call 800-799-SAFE (7233)
Crisis Text Line - Text NAMI to 741-741
Trans Lifeline - Call 877-565-8860
If you would like a printable copy of this application, please contact our Coordinator via email at info@dmacdenton.org.
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* Indicates required question
Email
*
Your email
Name*
*
Your answer
Personal Pronouns (she/her, etc.)
Your answer
Preferred Email
*
Your answer
Phone Number
*
Your answer
How many miles are you willing/able to travel to see a therapist on a weekly basis?
Access to transportation will not be a deciding factor on approval for our scholarship. You Are Here will partner closely with our therapists to seek options available to those who do not have access to transportation.
*
5-10 Miles
10-20 Miles
20-30 Miles
Do not have access to transportation
Mental Health Information
*You are not required to share deeply specific/personal information or diagnosis*
What are you interested in working on in therapy?
*
Your answer
Have you ever participated in individual therapy before?
*
Your answer
Would you prefer seeing a therapist on a weekly or biweekly basis?
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Weekly
Bi-Weekly
Do you have a preference in age, gender, race, or any other demographics of your therapist? Please specify
*
Your answer
Do you have a preference in area of expertise or sensitivity in your therapist?
*
Your answer
Any other preferences in regards to your therapist?
Your answer
*
Your answer
Financial Information
Your approval for the You Are Here Scholarship is not contingent on your financial situation or whether you have health insurance coverage.*
Do you have health insurance?
*
Yes
No
Does your health insurance have mental health coverage?
*
Yes
No
If your health insurance has mental health coverage, what is your co-pay?
*
Your answer
How much, if any amount, are you able to contribute to weekly or biweekly therapy funding, without this amount being a burden on basic needs?
*
Your answer
Send me a copy of my responses.
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