Application for Mental Health Support

Please fill out all required fields. This helps us understand your needs and provide the best possible support.

First Name*

Last Name*

Email Address*

Phone Number (Optional)

Street Address*

City*

State*

ZIP Code*

Number of Children*

Children's Ages*

Annual Household Income*

Insurance Status*

Type of Service Needed*

Additional Information*

I have read and agree to the Privacy Policy and understand how my information will be used.

I consent to receive communications regarding my application status and updates about You Choose Hope programs.

After submitting, you'll receive a confirmation email with your application ID and next steps.