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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.

 







Male
Female
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Financial Assistance
Referrals
Resources


Yes
No




Yes
No



Yes
No



Call
Text
Email


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