Request for community funded sessions (client form)

To access our Community Funded Sessions, you will need to meet ONE of the following criteria:

A) Low total household income OR

B) Exceptional circumstances make it difficult for you to fund psychological therapy or assessment

LOW TOTAL HOUSEHOLD INCOME

We use the Centrelink income test numbers to inform what is a low total household income. If your income is at or below the following then you may be eligible for our community funded sessions:

2 children	$117,000
3 children	$140,000
3 children	$157,000
5 + children	$174,000
NO children - single	$33,696
NO children - partnered	$67,000

EXCEPTIONAL CIRCUMSTANCES

We know that there are times when you may have a higher household income and therefore not eligible to use the low income criteria to access our community funded sessions, but there may be exceptional circumstances still preventing you from accessing this support because you are unable to afford it. These circumstances might be things like:

- Sudden and unexpected change in circumstances

- Death of a family member

- Family violence

- ATSI

- Transgender

- Mutiple children attending therapy/treatment

- Any other situation that you feel may be impacting your ability to fund ongoing psychological support

Name*

First NameLast Name

Date of Birth*

Date

Please advise if you are applying under the low household income criteria or the exceptional circumstances criteria. *

Also advise HOW you meet this criteria (for financial reasons, please advise your total household income and if you have children and are partnered. For exceptional circumstances, please advise what your circumstances are and how they are preventing you from accessing psychological support)*

Phone Number*

Please enter a valid phone number.

There is a $20 co payment for every session or every hour of funded assessment. Please confirm you are aware of and able to commit to this payment.*

YesNo

Client initiated request for CFS