Mental Health Financial Assistance

Financial Assistance

Mental Health Services
LGMF offers financial assistance for mental health care services to eligible individulas and families. Based on your financial need, a portion or all your mental health care session fee may be paid. We also consider past due balances if the provider requires payment before scheduling an additional session.

You may be eligible for assistance if you:
- Have limited or no health insurance
- Can show you have a financial need
- Have mental health care bills in an amount that exceeds your ability to pay
- Have already selected a provider and know the session fee
- Possess a strong desire to get back to the healthiest version of yourself
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Please select the one that applie

Single Married Divorced Widowed
Employer's Name
Spouse's Employer's Name
If married...
Monthly Household Income
Amount of Monthly Household Bills
Mental Health Provider
include name of provider, name of office, phone number and session fee
Explain your need for financial assistance
Be as detailed as possible
Signature

Clear
Should be Empty: