Sound Minds Application | Interfaith Community Outreach

Name of person filling out the application*

First Last

Contact phone number of person filling out the application*

Email address of person filling out application*

Relationship of the person filling out the application to the applicant*

Client Name*

First Last

Client Address*

Street Address City State ZIP Code

Client contact phone number*

Client email address*

Does the client speak English?*

How long resided in Dare County?*

Is client a minor?*

Client Date of Birth*

What type of insurance does client have?*

Has client recently seen a therapist?*

If so, what is the therapist name?

By submitting this application, I give Interfaith Community Outreach (ICO) permission to verify any information necessary to determine my eligibility for participation in the Sound Minds Program. I authorize ICO to discuss my household’s situation with members of the Dare County Department of Health and Human Services, therapists and insurance billing departments and any other organizations necessary to identify appropriate assistance. I understand that there are regulations protecting the confidentiality of authorized information to verify assistance received or denied. I hereby acknowledge that this consent is truly voluntary and is valid for 12 months. I understand that I may revoke this consent at any time except to the extent that information has already been released before I revoke it.

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

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