GHI Fund — Intake Form

About you

First name *

Last name *

Email *

Phone *

Date of birth *

Emergency contact *

Address *

Languages you're comfortable in *

English Hebrew Russian French Spanish Arabic Other

Which other language? *

How did you hear about the program? *

Military service

Service start date *

Current status *

If "Other", please specify *

IDF identification number / Chogeh number *

Upload ID document (jpg, png, pdf) *

Stored securely and used only to verify your eligibility.

Therapeutic Goals

Have you previously received any type of mental health services? *

Please describe *

What would you like to accomplish in therapy? *

Please rate your level of distress today (1 = low, 10 = severe) *

Selecting a therapist *

Already contacted my selected therapist Need assistance selecting a therapist

Please select the participating therapist you would like to work with. We encourage you to choose a therapist based on the criteria that are most important to you. See the list of participating providers below for detailed information about each therapist.

Before making your selection on this form, please contact the therapist directly to confirm that they are available and that their schedule works for you. Selecting a therapist without confirming their availability first may significantly delay the processing of your request.

The best time to reach me is: *

Financial ability to contribute *

If "Other", please specify *

Confirm & sign

Type your full name as your signature *

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