Mental Health Client Contact Form

Mental Health Contact Request Form

Fill out the form below and one of our therapists will be in touch. *PLEASE NOTE- if you are experiencing a mental health emergency, call the Mobile Crisis Outreach Team (MCOT) 1-800-273-8255, or 911
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
example@example.com
The UAF Mental Health Program has worked to value equity and remove barriers to therapeutic spaces for LGBTQIA+ individuals who are uninsured, underinsured, or experiencing dificult life circumstances.

Our program currently offers three pathways to access counseling services:

Insurance

Income-Based Sliding Scale

Limited therapy scholarship for 12-16 weeks of therapy based upon extenuating financial or life cirumstances.
How would you like to pay?*

I would like to use the Self-Pay sliding scaleI would like to be considered for a UAF Therapy ScholarshipI would like to use my insurance company, and will list it in the option below:Other
Have you accessed services at UAF before?*

YesNo
Please briefly tell us why you are looking for counseling services. *These answers are confidential.
Thank you for reaching out!

One of our therapists will be in contact within 48 hours.
Should be Empty:

Mental Health Contact Request Form