Begin Your Application for Funding
Name
*
First Name
Last Name
Credential
Business Name
*
Market Area
*
Closest major city in your service area
E-mail
*
Business email address
Phone Number
*
-
Area Code
Phone Number
Understanding and Agreement
Signature.
*
Your Client's Medical Needs
Please list Client's medical needs.
*
Please be brief and try to list in order of priority.
What are your Client's goals?
*
Briefly state. Add your additional goals, if any.
Your Plan of Service for Client
Describe what you will do to address client's medical needs and meet goals.
*
Briefly state.
Estimate of Time Required
How many hours of professional time will you need to address client's concerns and goals?
*
One hour or less
2 - 3 hours
4 - 6 hours
More than 6 hours but I will donate the extra time myself
Choose one
Your Assessment of Financial Need
How did you determine that your client qualifies for funding?
*
No health insurance
Covered by Medicaid
On disability
Out of work/unable to work
Homeless
Bankruptcy
Other* (answer next question below)
Check all that apply
Anything else you would like to add?
Optional
Thank you for sharing this opportunity to help.
We will respond within 24 hours -- sooner, if possible. If your request is urgent or especially time sensitive, TEXT Karen Curtiss at 847.208.6074
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