Focus CSI Application Form |

Thank you for your interest in Focus CSI. Focus CSI is a Georgia-based community service initiative aimed at making quality naturopathic care available to all in the Atlanta area. Focus CSI takes place on the fourth Monday of each month. The deadline to submit your application is the third Monday of each month. Each month, we select 4 applicants to be seen for a 30-minute appointment at our practice at minimal cost (70% off to completely free). To apply to be seen, complete the form below. Please note that you must be able to come in to the office in order to participate in Focus CSI (we will not be available for telehealth appointments on that day).

In order to give you an income-based discount on our health services, it is necessary for us to ask some personal questions. Our web site is encrypted (secure) and your answers will be kept on file and in strict confidence. This application form is best completed on a desktop or laptop computer rather than a mobile phone. If you have questions about Focus CSI or completing your application, call (404) 532-9548 or use the chat box at the bottom of the page during our normal business hours.

***Note: In order for the form to function properly, please ensure that you have entered a response in each box. You may write N/A in boxes that do not apply to your situation. Please also make sure that you check the box at the end. If you experience difficulty, call us or send us a message. We’re here to help!***

If you are interested in contributing monetarily or supply-wise to making Focus CSI a success, call our office at (404) 532-9548.

Date of Birth:

Household Size: Please list all household members other than yourself, their relation to you, and their date of birth.

Household Income: Please list the income of all household members including yourself; whether the stated income is a weekly, monthly, or yearly income; and the employer.

Other Income: Please list any other income of all household members including yourself; the type of income, the amount and frequency, and the person receiving it. This includes social security, public assistance, retirement pension, food stamps, child support/alimony, unemployment benefits, any other government assistance, interest income, and any other type of income.

We will need to verify your income. Your yearly income tax return, a copy of your W-2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive will be sufficient proof. Your annual income and your family size will be used to calculate your discount. You may attach those documents here or fax them to us at (913) 210-5208.

Checking the box below signifies that you agree with the following statement:
I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the Focus CSI Program. I further agree to inform Focus Integrative Healthcare if there is a significant change in my income. If acceptance to the Focus CSI Program is obtained under this application, I will comply with all rules and regulations of Focus Integrative Healthcare. I hereby acknowledge that I read the foregoing disclosure and understand it.