Are you a Massachusetts Resident? *

Under state licensing laws and regulations governing mental health services, only legal residents of Massachusetts are currently eligible to participate.

Yes

No

Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have You Received Mental Health Treatment Before? *

Yes

No

Have You Been Diagnosed With a Mental Health Condition? *

Yes

No

Unsure

Are You Currently Taking Medication for Your Mental Health? *

Yes

No

Emergency Contact (Phone Number) *

(###)

###

####

Are You Currently Able to Contribute Partial Payment Toward the Cost of Sessions? *

Needs-based counseling is funded entirely by grants and donors. Each sessions costs the Paper Bag Mask Foundation $50-200.

Yes

No

Unsure

Acknowledgement *

I acknowledge and understand that Paper Bag Mask Foundation serves solely as a referral service and does not directly control, monitor, or guarantee the quality, availability, or outcomes of services offered by third-party providers. While Paper Bag Mask Foundation may cover certain costs associated with accessing these services, I agree all decisions to use the referred services are my own. I hereby waive any and all claims against Paper Bag Mask Foundation, and affiliates for any direct, indirect, or consequential damages, losses, or liabilities arising from my interactions with or use of the services provided. I understand that any financial assistance provided is subject to additional eligibility requirements and conditions, and that Paper Bag Mask Foundation is not liable for any billing or reimbursement issues. I acknowledge that Paper Bag Mask Foundation reserves the right to modify or terminate its referral services at any time without prior notice. I further understand that my eligibility for financial assistance are subject to review and available resources, and are not guaranteed.

I Agree