Mental Health Therapy Intake Form

Bright Heart Foundation is here to support our Congenital Heart Defects (CHD) community.  Please fill out the information below if you wish to inquire about our free or low-cost mental health therapy program options.

    Do you know of someone in need of support?

    Name of the person in need of support:

    Email of the person in need:

    Phone Number of the person in need:

    Age range of the person seeking mental health therapy:

    What state do you live in*?

    *Our therapists are only licensed to treat people that are residents in the state of Tennessee.

    Zip code of the person in need:

    How did you hear about Bright Heart Foundation?

    What time of day would be best for you to attend sessions?

    Would you prefer a 60-min or 90-min session?

    Would you be interested in:

    Anything you wish to share with Bright Heart Foundation:

    Bright Heart Foundation