Mental Wellness Form

Purpose of form

Salamualaikum and welcome!

This fully confidential form is intended to match you to a right fit mental health provider. Having a previous diagnosis will not impact your access to a therapist. We are grateful that you are taking a step towards your mental wellness! May Allah be with you - The Mental Wellness Team

Tell us about yourself

What is your gender?

Male

Female

Do you need an interpreter?

Yes

Can we contact you in English?

Yes

Do you have insurance? If so, which one?

What is your name? Your privacy is protected

What is your birth date? Your privacy is protected

What is your phone number? Your privacy is protected

What is your email address? Your privacy is protected

What is your zip code? Your privacy is protected

I give MYPI permission to release the information in this form to a right-fit provider. Your privacy is protected