Give an Hour Healthy Minds Fairfax Referral Form

 

Thank you for your interest in participating in the Give an Hour Healthy Minds Fairfax program. Give an Hour is a national nonprofit organization with a large network of mental health professionals who offer no-fee mental health counseling to those in need.   Give an Hour has partnered with Healthy Minds Fairfax (HMF), Fairfax County and the Cities of Fairfax and Falls Church, Virginia to provide free and confidential mental health services to income eligible youth and children between the ages of 5 and 21.

In order to gain access to the Give an Hour Healthy Minds program’s mental health providers/services in your area, please complete the form below. Please know, your name and demographic information will be kept confidential by Give an Hour and used solely for the purpose of anonymous tracking for the utilization of this program. Once you complete the information necessary, you will be contacted by a Give an Hour referral specialist who will work with you to find a suitable mental health provider in your area.  If you have any questions, please contact fairfaxcounty@giveanhour.org. If you have not heard from a Give an Hour referral specialist within 72 hours please contact info@giveanhour.org.

 

 

How to Access Individual Services

Please review and verify the following eligibility requirements to see if you or the child or youth you are seeking services for meet the requirements to be eligible for Give an Hour Healthy Minds Fairfax services.   

Eligibility Requirements: 


For income-eligible children and youth ages 5 to 21 who are residents of Fairfax County, the Cities of Fairfax and Falls Church, Virginia. In order to receive services, you must:

  • Be a resident of Fairfax County, or the Cities of Fairfax and Falls Church, Virginia.
  • Be between 5 to 21 years of age.
  • Meet the following income requirements:

Household Size 

Maximum Income 

$48,560 

$65,840 

$83,120 

$100,400 

$117,680 

$134,960 

$152,240 

$169,520 


By fill out the following form, you certify that you or the child or youth you are seeking services for meet the above requirements.

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We look forward to working with you and hope you find this resource helpful. Please fill out the information below and Give an Hour's Referral Specialist will be in touch with more information as soon as possible. If you do not hear from us within 72 hours, please contact fairfaxcounty@giveanhour.org.

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