The WellCare Foundation ~ Sign Up Today!

If you're interested in more information about WellCare Services and would like to find out if you're eligible, please fill out the form below. One of our staff members will contact you within five business days.

First Name
Last Name
Email
Mothers date of birth (mm/dd/yyyy)
All childrens full name and date of birth One child per line (First Last - mm/dd/yyyy)
Marital Status
Home Phone
Cell Phone
Address
Address (cont'd)
City
State AZ
Zipcode

Are you a single working mother? YesNo
If yes, who is your employer?

Are you a full-time student? YesNo
If "yes" what is the name of the school?

Are you on any state assistance for healthcare like AHCCCS? (Arizona Health Care Cost Containment System) YesNo
If "yes" what is the name of the plan?

Do you have Private Health Insurance? (through employer or on your own) YesNo
If "yes" what is the name of the plan?

Child(ren) on health insurance? YesNo

How many children do you have?

Are you children under age of 18? YesNo

What kind of healthcare do you feel you need?

What days and times are you available to get appointments?

Do you have transportation to be able to get to appointments? YesNo

"Because of WellCare and the whole health care team, my life has changed dramatically. I am truly happy. My kids are happy. I’m comfortable; not living in fear. I have support. I have hope. I have a place in society. "

Without the support and care of our practitioners, The WellCare Foundation could not provide such a rich range of healing therapies to our mothers and children in need.
more about our practitioners >