Heal It Forward · Reassessment

Update Your Information

Please share your current situation so our team can continue supporting you through the HIF program.

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Insurance Status

Do you currently have health insurance? *

Yes, I'm insured No, I'm uninsured

Please select your insurance status.

How would you describe your out-of-pocket costs? *

High deductible / large copays — I pay a lot out-of-pocket Moderate — manageable but still a burden Low / minimal copays — mostly covered

Please describe your out-of-pocket costs.

Financial Situation

What is your approximate annual household income? *

Under $20,000 $20,000 – $35,000 $35,000 – $50,000 Over $50,000

Please select an income range.

What is your current employment status? *

Employed full-time Employed part-time Self-employed / freelance Unemployed / seeking work Unable to work (disability, caregiving, etc.) Student Retired

Please select your employment status.

Current Situation

Please briefly describe any financial hardship or life changes since your last assessment. *

This helps our team understand your current needs. All responses are confidential.

Please briefly describe your current situation.

Consent

I confirm this information is accurate and I consent to Helen's Project using it to reassess my eligibility for the Heal It Forward program. You must confirm before submitting.

Your information is confidential and used only for HIF program eligibility.
Questions? info@helensproject.org · helensproject.org