If you are experiencing a mental health emergency, dial 911 or 988 immediately.

〰️

We will respond to all requests within 72 hours.

〰️

If you are experiencing a mental health emergency, dial 911 or 988 immediately. 〰️ We will respond to all requests within 72 hours. 〰️

Mental Health Assistance

First Response Wellness Foundation wants to help you ensure that you are with us for a long time and that you continue to provide for your community. We understand that the things you see are sometimes stressful.

Let us help you, we will pay for you to speak in person, with a mental health professional.

We will review your request and provide you with a response within 72 hours.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

Phone Number

This number must be able to receive text messages.

(###)

###

####

State of Residency

Agency You Are Affiliated With

Title within Agency

Supervisor Phone number

We will NOT inform your supervisor that you are seeking mental health assistance.

(###)

###

####

Psychologist/Psychiatrist Name

Psychologist/Psychiatrist Phone Number

Please make sure this is a valid contact number for the mental health office.

(###)

###

####

Requested Funding Amount

Please provide the quoted amount from the mental health professional. If you don't know this information, please put $1, we will find out the cost.

$