Mindful Access Program

Equity- Driven Healing

Please correct the errors described below.

Contact

dryang@mindfulsolutionspsych.com

(5559) 620-1876

Name

Date of Birth

Email address

Phone number

Requested Service

Psychological Evaluation

Specify (if known):

Individual Therapy

Eligibility Checkboxes (check all that apply)

Household income below $80,000 annually

Currently enrolled in school or college

Receiving public assistance (Medi-Cal, SNAP, SSI)

Experiencing recent financial hardship (job loss, medical, caregiving, etc.)

Referred by a community agency, school, or nonprofit

Other

(please describe):

Please describe why reduced-fee or payment plan access would be helpful at this time

Preferred Payment Option

Siding Scale (reduced fee)

Payment Plan

Not sure

Your information will be encrypted.

Contact

dryang@mindfulsolutionspsych.com

(5559) 620-1876

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