Kansas City Black Mental Health Initiative

KCBMHI Client Questionnaire
*Disclaimer: The Black Therapy Fund is subject to funding, and it is not guaranteed.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth (MM/DD/YYYY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you an Uzazi Village Client? *

Yes No

Are you a current resident of Jackson County, MO? *

Yes No

Gender *

Have you seen a mental health professional before? *

Yes No

What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can. *

Submit