Financial Assistance Request Form

Hearts Connected's Financial Assistance Program exists to help eliminate financial barriers that keep families from accessing mental health care and support. As insurance reimbursement for child life services is not an option, we are committed to making our therapeutic sessions accessible to more families.

Scholarship Guidelines

Hearts Connected, LLC offers financial assistance on a first-come, first-served basis for individuals that demonstrate financial barriers to accessing mental health care.

In order to serve as many individuals as possible, Hearts Connected, LLC limits the number of sessions based on the funding received.

If services are not sought or discontinued within 30 days, the funds will be released to another applicant.

Criteria

Funding is dependent on the availability of funds at the time of scholarship application.
Participant need is required, including a case for support.
Participant commitment is required. Clients must arrive to scheduled appointments on time and complete his/her session.

Please select:*

We are requesting support for the total amount of a session due to a financial hardship.We are requesting to pay a reduced fee of the total amount of a session or service.

Caregiver's Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Address

Dependent Information

What is your current combined household income per year?

Please describe the nature of your financial hardship. *

Briefly explain why you are seeking support for your child and any other immediate needs or concerns. *

I acknowledge and understand the requirements and guidelines for the Hearts Connect, LLC financial assistance application. I certify that the above information is accurate and complete to the best of my knowledge. I give Hearts Connected, LLC permission to verify all of the above information. I understand that any incorrect information will result in immediate termination of this request.

Signature*

Date*

MM-DD-YYYY