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Copay Relief Request

Full Name

Email Address

College or University

Are you a current client at Intersect or starting intake?

Are you a current client at Intersect or starting intake?
A
B

Is your student health insurance plan currently active?

Is your student health insurance plan currently active?
A
B

What is your therapy copay amount?

What changed recently to make copays harder to afford?

Are you on a scholarship, financial aid, or restricted from working (e.g., visa limits)?

Are you on a scholarship, financial aid, or restricted from working (e.g., visa limits)?
A
B

Is there anything else you'd like us to know about your situation?

I agree that the information provided is accurate and understand Intersect may follow up with me.

I agree that the information provided is accurate and understand Intersect may follow up with me.