If you think you may qualify for services, please call 214-821-3820 for a pre-screening. If you qualify, you will be directed as to which forms below to download and complete.
| Form | Description | Lang | Format |
|---|---|---|---|
| Application | Application Form (Checklist, Intake, Financial Assistance Policy, Consent Agreement) | English | |
| Editable Application | Editable Application Form (Checklist, Intake, Financial Assistance Policy, Consent Agreement) | English | Word |
| Aplicación | Aplicación (lista de verificación, Intake, Politica de Asistencia Financiera y Descargo de Responsabilidad, Acuerdo de Consentimiento) | Español | |
| Aplicación editable | Aplicación editable (lista de verificación, Intake, Politica de Asistencia Financiera y Descargo de Responsabilidad, Acuerdo de Consentimiento) | Español | Word |
| Medical Release | Release for Medical Records and Imaging Studies | English | |
| Supporter Statement | Used for verification of support from someone other than your spouse | English | |
| Employer Verification | Verification of employment and insurance | English | |
| Notice of Private Practices | Notice of Private Practices Form | English | |
| Formulario de aviso de Prácticas Privadas | Formulario de aviso de prácticas privadas | Español |