Professional Referral Request an Appointment

Farmer Mental Health Support Program Community Access

Note: This form should not be used in the case of urgency or emergency. If this is an emergency, please contact 911 or proceed to your nearest emergency room.

As administrators of the program, Counseling Associates supports the option of farm owners working with their own therapists. We are willing to on-board eligible therapists who meet the program's criteria. If you are interested, please fill out the form below and we will contact the therapist once we have your documented permission.

Eligible therapists will be licensed for independent practice in New Hampshire and agree to the reimbursement terms of the program.

Upon receipt of this participant registration and the provider application, eligibility will be reviewed and you will receive a contact from our Program Coordinator. Thank you!

(* required info)
First Name *
Last Name *
Date of Birth * (mm-dd-yyyy)
Farm Name*
County*
Street Address*
City*
State*
Zip*
Phone *	(do not include 1- prefix)
OK to Leave Message *	Yes No Please choose yes or no
E-Mail Adr *
Are you a farm business owner who materially participated in the business?	Yes No Please choose yes or no
Have you owned and operated your farm business for at least one season (including this current season)?	Yes No Please choose yes or no
My farm sells at least $1000 in products that we produce and we fill out Schedule F tax forms.	Yes No Please choose yes or no
Your Preference *	I would like to access up to 10 sessions funded by this program. OR I would like to use my insurance and have this program cover out-of-pocket expenses including deductible and co-pay up to a cap of $1,200. (please complete insurance information below) You must check one or the other box
Community Therapist Name
Community Therapist Phone # *	(do not include 1- prefix)
Therapist E-Mail Adr *
Download Health Information Release (pdf)	Authorization to Disclose Health Information (pdf)
Upload signed Outside Provider authorization form (PDF only)
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Farmer Mental Health Support Program Community Access

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