Eligibility Questionnaire

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Are 18 years of age and older? *

Do you reside in either Lee, Collier, Charlotte, Hendry, or Glades counties? *

Do you have a current mental health diagnosis provided by a licensed mental health care professional? *

Do you currently have private medical insurance? *

If you have private medical insurance, you are not eligible for our program

Do you receive, applying to receive, or actively appealing a decision to receive SSDI or SSI? *

SSDI: Social Security Disability Insurance: SSI: Supplemental Security Income

you appealing on

Do you have a case manager or a resource coordinator? *

If yes, Participants must be willing to discontinue case management to qualify.

Are you legally able to make decisions on your own behalf and not have a court appointed legal guardian. *

If you have a legal guardian, you are not eligible for our program.

First & Last Name *

Phone Number *

Please include the area code