Mental Health Assistance

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Applicant Details

The Journey Fund has partnered with Alicia Gutierez, M.A. in Counseiling at Polis Recovery Project to provide emergent counseling services to individuals receiving cancer treatment. This fund is intended to serve uninsured and underinsured individuals and/or individuals who are unable to access mental health care due to long wait times. Approved applicants will be provided with an approval number that they will use to schedule their free mental health sessions. Aplicants will be eligible for:

  • Three free counseling sessions with Alicia Gutierez, M.A. in counseling at Polis Recovery Project.
  • Counseling available in English and Spanish.
  • Tele-mental healh or in-person visits available. 
Name
Address
Date of Birth
Sex
English speaking?
Race/Ethnicity. Please check all that apply:

Applicant Need & Supporting Documents

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Legal

Authorizations
In order for TJF to process this application the applicant must consent to at least the first two authorizations. *** Please note, if you consent to having your photographs, quotes or videotape images to be used for publicity/publications, TJF would contact you directly to obtain photographs/videotape images. This consent does permit us to use quotes from this application in publicity/publications.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
Mental Health Disclosures
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Healthcare Representative Information

Name
Verifications
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

*** Please note, your application will be reviewed within 30 days of the submission date. If you have any questions, please email chair of the application commiteee, Donna Banks, dbanks@nwmsonline.com.