DHWCares Free and Low Cost Counseling

DHWCares Free and Low Cost Counseling
Client Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Provider at DHWC (if unsure or unknown, enter "NA")
Diversified Health and Wellness Center offers free and low-cost counseling services to those who qualify through our 501(c)(3) non-profit organization, Diversified Cares. We offer a sliding scale from $0 - $50/session, or we may waive the session fee entirely based on financial need. Please note that fees for late cancellations/arrivals or missed appointments will still apply. Please check the following boxes that apply to your current financial situation:
I certify that I qualify for free or low-cost counseling based on the following reason(s) and explanation(s) listed above.

Client or Parent/Legal Guardian Signature: Signature*
Date: Date*
Please provide any additional information that will explain your specific situation, and how we may assist you.
For Office Use
Client Fee Per Session
Provider Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinical Director Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

For Office Use