THE ASSISTANCE REQUEST FORM

If you are in need of any assistance regarding mental health, please continue to fill out this form. Whether it's with finances for a mental health service you are receiving, a referral for a mental health service you are seeking, or if you are just in need of a resource, you name it.

Please note that all fields are required.

Name

Email

contact.form.phone

What can we help you with?

Date of Birth
Town or City You Reside In
Gender
Male
Female
Prefer Not to Say

What type of support are you looking for?
Financial Assistance
Referrals
Resources

Do you have insurance?
Yes
No

If yes, what type of insurance do you have?

Is there a co-pay or out of pocket expense?
Yes
No

If yes, what is that cost?
Do you have an outstanding bill? If so, what is the balance?
Yes
No

Please provide the name and phone number of the business or organization who referred you to fill out this form.
What is the best way to contact you? (You may select more than one.)
Call
Text
Email

How did you hear about us?

The Butterfly Path Team will review your request and be in touch shortly. We want you to know that this will stay confidential.

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