Counseling assistance Program

If you are struggling with the costs associated with receiving mental health counseling, you can apply for counseling assistance from Toned Out Project.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

First Responder Affliation and Position

Are you uninsured for mental health services?

Are you underinsured for mental health services?

If yes, please describe your current coverage limitations:

Briefly describe your financial need for counseling assistance:

Do you have a preferred counseling provider?

Not required

First Name

Last Name

Phone

(###)

###

####

Are you currently receiving counseling services?

If yes, how many sessions have you completed?

Do you have anything else to add that you would like us to know?

I certify that the information provided in this application is accurate to the best of my knowledge. I understand that funding is subject to availability and agree to adhere to the program guidelines if approved.

By typing my name in this box, I agree to this statement.