The GHI Fund Subsidized Therapy

First Name

Last Name

Date of Birth

Phone

Address

Language(s) spoken fluently in which therapy can be conducted

Hebrew English French Yiddish Russian Spanish Other

Emergency Contact (name, phone number, and their relationship to you)

How did you hear about this program?

Date of the start of your service in the IDF?

Please select your current status in the IDF

I'm an active IDF soldier I'm an active lone soldier I'm an active reservist I have completed my service in the IDF Other

IDF identification number

Please upload your IDF ID (or Miluim ID if you're an active reservist)

DISCLAIMER

THE GET HELP ISRAEL FUND / BRIUT HANEFESH LEKULAM IS A NON-PROFIT ORGANIZATION THAT HELPS TO PAY FOR THERAPY FOR SOLDIERS AND RESERVISTS RETURNING FROM SERVICE. THE TREATMENT THAT CLIENTS RECEIVE IS THROUGH THE THERAPIST'S PRIVATE PRACTICE. GET HELP ISRAEL AND BRIUT HANEFESH LEKULAM IS NOT RESPONSIBLE FOR THE THERAPY PROVIDED ONCE THE MATCH HAS BEEN MADE. IF YOU ARE UNHAPPY WITH THE MATCH, YOU MAY CONTACT US AT [email protected] AND REQUEST A DIFFERENT THERAPIST.

By signing your name below, you attest that you understand the terms of service outlined above and that all the information on this form is accurate to the best of your knowledge.