Thank you for your interest in Direct Care. Our membership model is designed to provide consistent, affordable, and high-quality mental health support. By completing this form, you’ll help us determine what offerings will best serve our community and at request you'll be added to our waitlist.

Please note: When you join the waitlist, it does not guarantee immediate enrollment.

Interest Survey/Wait List

Date *

Full Name *

Date of Birth *

Email *

Phone *

Preferred Method of Contact *

Phone

Text

Which benefits would be most important to you? (Select all that apply)

What price range would you consider affordable for a therapy membership?

$100–149/month

$150–199/month

$200–249/month

$250+/month

How interested would you be in family or couples membership options?

Not interested

Somewhat interested

Very interested

Would you like to be added to the waitlist for early access when we launch?

Yes

No, just gathering information

Self-Attestation

I have read and agree to the Terms & Conditions.

Consent

By submitting this form, I consent to the collection and use of my responses by Emerging Hearts Mental Wellness Center, PLLC for informational and service improvement purposes. I understand that submitting this form does not establish a therapist–client relationship, when services are available I will be notified and will have 48hrs to respond. I understand that any information shared will be kept confidential in accordance with HIPAA and applicable privacy laws.

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