Confidential

Client Application Form

Your one-time, application fee of $49 supports our nonprofit organization in achieving this important mission and allows you to apply for our quarterly IVF scholarship as well as access 6 free counseling sessions with one of our qualified therapists.

Personal Information

Name

First Name

Last Name

Confirmation Email

Phone Number

(###)

###

####

Date of Birth

YYYY

Race/Ethnicity

Gender

Full Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Financial Information

Our nonprofit serves military clients in financial need who are seeking free therapy due to fertility related challenges and expenses. Our military clients cannot afford market rates for therapy.

Annual Household Income

Annual Fertility Related Expenses

How Did You Hear About Us?

Active Duty Service Branch and Rank

Therapy

A few questions regarding therapy

Individual or Couples Counseling?

Anything else your therapist should know?

FREE SESSION FEE AGREEMENT

Mark each option

I am a military member or spouse who cannot afford the cost of market rate therapy sessions

I understand that I will receive 6 free mental health counseling sessions from a qualified and vetted mental health therapist and after those 6 sessions I will be responsible for making payment arrangements with my therapist

I agree to pay the one-time $49 membership fee to Mindful Warrior Alliance.

I understand that all therapists, including fully licensed therapists and those working toward licensure, have been personally vetted by Mindful Warrior Alliance and practice under active clinical supervision or licensure in their respective states. I acknowledge that Mindful Warrior Alliance is a nonprofit connecting me with independent therapists and is not liable for clinical outcomes or decisions made within therapy.

I acknowledge that Mindful Warrior Alliance is a nonprofit connecting me with independent therapists and is not liable for clinical outcomes or decisions made within therapy.

Clients Full Name

Today's Date

YYYY

By typing your full name here you certify your agreement to the above clauses and you agree to our Terms of Service

Client's Electronic Signature

NEXT STEPS

After you submit your registration form, we will guide you in how to pay your $49 application fee. After the fee is paid, we will email you a link to schedule a 15 minute consult with your therapist, to ensure you are a good fit. This email will also contain your therapist’s contact information. Please note that all of the information contained in this registration form is for Mindful Warrior Alliance’s administrative use only. It will never be made public under any circumstances and will only be shared with your prospective therapist.