Apply for Assistance X/TwitterThis field is for validation purposes and should be left unchanged.Name(Required) First Last Email(Required) Phone(Required)Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Physical Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you have medical insurance?(Required) Yes No Do you need financial assistance for mental health or addiction treatment services?(Required) Yes No Do you need help locating resources to support your mental health or addiction treatment(Required) Yes No Briefly describe the type of assistance you are inquiring about?(Required)What days and times are you available for a call back to discuss your inquiry for assistance?(Required)
