Referral Services Request THIS IS FOR NON-EMERGENCY REFERRAL SERVICES. If you have an emergency dial 911 or 988 Name * First Name Last Name Email * Phone * (###) ### #### Your Address Address 1 Address 2 City State/Province Zip/Postal Code Country Please provide a brief reason for requesting therapy services. * Do you have health insurance? * Yes No Not Sure If yes, Who is your insurance provider? * Do they cover mental health service? * N/A Yes No Preferred Language * Your Age * How did you hear about us? * Service experience * Are you willing to complete a survey of your experience after you have completed your therapy sessions? Yes No Indemnification: * Applicant will indemnify and hold MFF harmless from and against any claims, actions, liabilities, damages, costs and expenses (including attorneys' fees), regarding but not limited to (i) loss of life, bodily injury or damage to property, arising from any negligent or intentional wrongful act or omission by our PROVIDER or any of its employees, agents, representatives or subcontractors; (ii) Provider’s violation of applicable federal, state or local law or regulations; or (iii) Provider’s material breach of this request. Yes Thank you for reaching out to Muslim Family Foundation. Our team is currently reviewing your request, and we will get back to you as soon as possible.
