Request Assistance Application

Please ensure you have enough time to complete and submit this application — with required documentation — in one sitting, as it does not “save as you go”.

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Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Gender Identity
Race
Family Size (How many people are on your tax return)*
Immigration Status (Status can affect eligibility for health insurance)*
Email*
I would like to receive email updates from Music Health Alliance.
- Yes
- No
Phone*
How Can We Help?*
Please choose all that apply. The MHA Team will be back in touch within 48 hours.
How Did You Hear About Us?
Quick note about how we can help.*
What is your music industry affiliation?*
Years in the Music Industry*
Genre
Are you a current Music Health Alliance client?
- Yes
- No
If you answered YES above, who is your advocate? Please select the advocate that you have worked with previously at Music Health Alliance.
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Name
This field is for validation purposes and should be left unchanged.

Request Assistance Application

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