Counseling Assistance Application NOHF/COCNHF

Application for Counseling Assistance
ELIGIBILITY

Any member with a diagnosed, eligible (factor deficient) bleeding disorder, or their caregiver living in the same home, is eligible to apply for $400 per calendar year to assist with the cost of deductibles and other out-of-pocket expenses that are not covered by insurance for counseling.

Those with special circumstances are encouraged to apply for additional funds if needed.

Please provide all information necesary for us to pay the vendor below. Failure to do so may result in a delay in approval and processing. Direct reimbursements are discouraged and cannot be guaranteed without prior approval from GOBDF staff.

Please contact your HTC social worker or tracy@gobdf.org with any questions.
First Name*
Last Name*
Age*
Type of Bleeding Disorder*
Which Hemophilia Treatment Center are you seen at?
I give my HTC or treating hospital permission to confirm my/my family members' bleeding disorder diagnosis with chapter staff.

Yes (Required to attend programs and receive services)No
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email Address*
Name of Counselor/Mental Health Provider*
Office phone number of Counselor/Mental Health Provider*
Address of Counselor/Mental Health Provider (please ensure that this is the correct address for receiving payments)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current bill from practice (Please attach)*

Cancelof
Notes/Comments/Special Requests
Should be Empty:

Application for Counseling Assistance