Naseeha USA Financial Assistance Registration

This form is to register for Naseeha USA Therapy program for those who require financial assistance through our sliding scale. Please fill out the form below and our therapy team will reach out to you via email to determine your eligibility.

Full Name

Date of Birth (ex. October 1, 1990)

Phone Number

State of Residence

Email Address

Therapist of Interest (Please select a therapist in your state of residence)

Reason for Seeking Therapy

Who will be receiving therapy? (ex. Myself, my child, a senior)

If therapy is for someone else, please list their age and state of residence.

Additional Notes?

Please Attach One Month's Paycheck*

Drop your files here to upload