Form emergency assistance | 2 of Hearts Healing

First name

Last name

Birthday

Month

Day

Year

I use your birth chart to deepen and personalize healing recommendations. What time were you born? AND what city and state were you born in?

Phone

Email

Preferred Name? (if different)

Preferred method of contact?

Phone

Text

Email

Are you currently in immediate danger or a life-threatening emergency? Yes or no? ( If you are an immediate danger, please call 911 or go to your local crisis center or emergency room immediately. This form is not monitored in real time.)

Please briefly describe what is happening right now and what kind of support you are seeking.

What areas do you currently need support with? Select all that apply..

Where are you currently in your recovery journey? (You do not have to already be clean in order to apply for help. You will not be discriminated against if you are using.)

Are you currently connected to any recovery, medical, or support services?

How urgent is your situation?

Immediate (within 48 hours)

Urgent (within a few few days)

Important but not urgent

Please acknowledge the following:

I understand that 2 Of Hearts does not replace emergency services or medical care.

I understand that submitting this form does not guarantee assistance, but my request will be reviewed with care.

I consent to being contacted regarding this request.

Is there anything else you would like us to know that would help us support you better?

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