Apoyo Health & Wellness

Your Health, Our Priority

Apoyo Health and Wellness provides comprehensive health support including STD/STI linkage services, mental health resources, and care coordination. All services are confidential and judgment-free.

Apoyo Health & Wellness Application

Request health and wellness support services.

Personal Information

Full Name *

Email *

Phone Number *

Date of Birth

Gender Identity

Pronouns

Race / Ethnicity

Address

Street Address

City

State

ZIP Code

Household Information

Household Size

Annual Household Income

Employment Status

Additional Information

What type of health service are you seeking?

Do you currently have health insurance?

How urgent is your need?

Preferred method of contact?

Application Details

Why are you applying for this program? *

What specific needs do you have?

Additional Information

Supporting Documents

Please submit all supporting documents:

GOVERNMENT-ISSUED DRIVER LICENSE OR ID
COPY OF UTILITY BILLS (FULL BILL REQUIRED FRONT AND BACK)
COPY OF LEASE AGREEMENT
Proof of eligibility

Click to upload or drag and drop

PDF, DOC, or images up to 10MB

I certify that the information provided is true and accurate. I understand that Evangeline will review my application and contact me regarding my request. I consent to Evangeline storing and processing my personal information for the purpose of this application.