Pro Bono Therapy Request Form

Endeavoring Wellness offers pro bono (free) therapy services to folks who have very limited income and who cannot afford to pay full rates for therapy services. Spots are limited and we like to ensure that they are being allocated where they are most needed. Please fill out this form to help us learn more about your individual situation.

Please note that I am not currently scheduling new pro bono clients at this time. By filling out this form, you will be added to the waiting list to be contacted when availability opens.

Your name

Email address

Phone number

Location

PA NJ

How did you hear about Endeavoring Wellness?

Have you read the FAQ?

See here: https://e2wellness.com/faqs/

Income & Household Size

Do you currently receive income?

Yes No

What is your monthly household income after taxes?

How many people in your household does this income support?

Is your current financial situation fixed (e.g. SSI/SSDI benefit, Survivors benefit, retirement income), or is it the result of a crisis situation (e.g. temporary short-term injury, period of employment, temporary suspension of benefits, etc)?

Fixed Crisis

Is your current financial situation likely to improve in the next six months?

Yes No

Pro Bono Therapy Agreement

I attest that I currently cannot afford full rates of therapy services ($60-185 per session).

I attest that I can attend weekly sessions for individual counseling. If offered a pro bono opportunity, I commit to doing so.

I understand that these pro bono spots are for clients in need who cannot otherwise afford to seek treatment and I agree to not take advantage of this opportunity if I can afford to pay for therapy services.

I agree to notify Tajante Wainwright, BS immediately if my financial situation changes such that I can afford to pay for therapy services and am no longer in need of a pro bono spot, recognizing that this will allow the spot to be given to someone who need it.

I agree that the information that I have provided on this form is true and may be used to assess my eligibility for a pro bono spot. I understand that a spot may not be available at the time that I apply, that my financial situation may not qualify me for pro bono services, or that my therapeutic needs may not be a good fit for this practice. I agree that, if offered a pro bono spot, I will notify Tajante Wainwright, BS within two (2) calendar days of my intent to accept or reject the spot, and that the offer may be forfeit if I do not answer within this time-frame.

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Pro Bono Therapy Request Form

Please note that I am not currently scheduling new pro bono clients at this time. By filling out this form, you will be added to the waiting list to be contacted when availability opens.

Tajante Wainwright, BS

Advanced Masters Intern, Endeavoring Wellness Clinical Therapy & Consultation