Access to Wellness Referral Form

Please complete 1 submission per Access to Wellness Award Request



The purpose of the Access to Wellness program is to leverage existing resources and partnerships to develop a coordinated response that is supportive of individuals who often present within multiple systems.


The overarching goal of the Access to Wellness program is to support community tenure, successful recovery, and positive long-term outcomes for individuals diagnosed with a severe mental illness.

If the recipient is currently unhoused, check the homeless box below and this field will no longer be required.

Client County*

Required for funding.

Income Source*

Please select the multiple systems that the client is currently involved with. (Two systems must be selected to meet eligibility requirements)

Please Include email address and phone number

Please include email address and phone number

Provide details including total funding request. Please include services/ supports needed such as type of housing provided, recovery gap needs, treatment, emergency basic need items, transportation and psychiatric home health needs.

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