Mental Health Support Grant Application

Ray of Hope Mental Health Support
Grant Application
HIPAA Compliant

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APPLICATION MUST BE COMPLETED BY THERAPIST REQUESTING CLIENT GRANT FOR MENTAL HEALTH Do not send medical records
Date*

MonthDayYear
Date
Who Is receiving grant?*

Cancer PatientFamily Member of cancer patientCaregiver of cancer patient
Relationship to cancer patient (if not cancer patient)

SpouseChildParentGrandparentPartnerSiblingOther
Cancer Type
Which facility is cancer patient receiving treatment at?*
Client has internet access*

YesNo
Client has insurance*

YesMedicaidNo
APPLICATION PROCESS STOPPED

Any client that has Medicaid MUST ONLY receive services from a therapist that accepts Medicaid.

WARNING - If a client receives treatment from a provider that does not take Medicaid, even if they pay out of pocket, they can be dropped from Medicaid.
How old is client?*
Has client received therapy in the past?*

YesNo
If no, is it due to any of the following*

Therapy is too expensiveNot knowing what therapy isNot knowing how to find helpEmbarrassment about needing/wanting therapyOther
How do you think therapy can help you*

Help dealing with my illnessHelp for my family during treatmentReduce stressEnhance quality of lifeImprove self-careProgression of illnessLoss of life due to illnessOther
What Colorado county does client live in?*
What language/s does client speak?*

EnglishSpanishOther
Family Size of client
Monthly Income of client
Marital Status of Client*

SingleMarriedPartneredDivorcedWidowedDomestic Partner
How does client identify?*

MaleFemaleTransgenderNonbinaryOther
The questions in this section are optional, and your answers are confidential. This information is reported anonymously, to help policymakers and advocates better understand and address health disparities in underserved groups.
Client Sexual Orientation

HeterosexualGay/LesbianBisexualAsexualOther
Client Ethnicity

African AmericanAsian or Pacific IslanderHispanicNative AmericanWhiteOther
Client Education

Grade SchoolHigh SchoolVocational SchoolCollegeGraduatePost-Graduate
Patient Privacy Policy

The code provided below will be utilized by you (therapist) and the Ray of Hope Cancer Foundation to facilitate payment for an approved Mental Health Support Grant. Please include the code provided below on ALL of client's invoicing as we should not know client's identity.
Form will generate your five digit alphanumeric code - letters and numbers (example LAR45)
Patient Code First
Code
Patient Code Last
Therapist Name*
Therapist Email*
example@example.com
Practice Name*
Grant Agreement Acknowledgement (Billing Policy)

By submitting this application, you acknowledge and agree to the following: • This is a one-time grant per client. • Once awarded, you cannot reapply for the same client. •The grant provides up to $600 per client. • No additional funds will be issued once this amount is exhausted. • Session rates are at your discretion; however, reimbursement per client will not exceed $600. • Grants are awarded on a first-come, first-served basis until funds are depleted. Billing Deadlines: • You may invoice after any completed session. • All invoices must be submitted within 30 days of the client’s final session. • All invoices must also be submitted no later than January 30 following the end of the fiscal year (December 31). • Invoices received after these deadlines will not be accepted or paid.
Signature*

Clear
Should be Empty:

Patient Privacy Policy

Grant Agreement Acknowledgement (Billing Policy)