Basic Membership

Terms:

$100 / Year

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Date of Birth:* Date of Birth is Required

Gender:* Gender is Required

Male Female Non-binary

Is this your first time seeking mental health services?:* Is this your first time seeking mental health services? is Required

Yes, I have never been to, or sought therapy before No, I have sought therapy before and/or already have a therapist I have sought services before, but never went

Are you currently in a crisis?:* Are you currently in a crisis? is Required

Yes No

Do you have a sense of happiness or support currently?:* Do you have a sense of happiness or support currently? is Required

Yes No A little

Signing up for my child:* Signing up for my child is Required

Yes No

I understand that my membership cost constitutes as a donation for this organization and is nonrefundable *

I acknowledge that I have read and accept the terms and conditions and privacy policy*

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Strong" or stronger

Coupon Code:

Invalid Coupon

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