GHI Fund — Miluim Spouses Intake Form

About you

First name *

Last name *

Email *

Phone *

Date of birth

Number of children

Emergency contact

Address

Languages you're comfortable in

English Hebrew Russian French Spanish Arabic Other

Which other language?

How did you hear about the program?

Your current military status (if applicable)

Spouse's military status *

ID / Teudat Zehut number

Upload ID document (jpg, png or pdf)

Stored securely and used only to verify eligibility.

Areas you're most struggling with

Anxiety Depression Trauma / PTSD Relationship difficulties Grief / Loss Parenting stress Sleep Loneliness Other

Have you previously received mental health services?

Please describe *

What would you like to accomplish in therapy?

Current distress level (1 = low, 10 = severe) *

Preferred therapist (optional)

Financial ability to contribute *

If "Other", please specify *

Type your full name as your signature *

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