King of Kings Counseling Financial Assistance Application

King of Kings Benevolence Counseling Application

“Be joyful always; pray continually; give thanks in all circumstances, for this is God’s will for you in Christ Jesus.” - 1 Thessalonians 5:16-18
King of Kings Church is accepting applications for financial assistance related to counseling. Benevolence counseling will extend to no more than three counseling sessions, paid in partial or in full.

Fill out the Benevolence Counseling application completely. Take a clear photo or scan the following documents to be submitted
1. Current Photo ID
2. Front of your insurance card (if applicable)
A King of Kings committee will review your application and return an answer within 5-7 business days.

If approved, you will receive information about how to schedule an appointment, and payment for sessions will be handled between King of Kings and their contracted counselors.
Note: This form is not intended for requesting financial assistance for utilities, rent, medical bills, or similar needs. Requests of this nature submitted through this form will not be addressed. This form is exclusively for applying to receive a counseling scholarship.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Are you employed?*

YesNo
Copy of current driver’s license*

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Phone Number*
Email*
example@example.com
How did you hear about King of Kings?

I am a King of Kings MemberI am a King of Kings VolunteerOther

Your Need
Please select the kind of counseling you are looking for.*

Individual counselingCouples counselingFamily CounselingCounseling for a minor
Please describe the reason you are seeking counseling.*
Note: This form is not intended for requesting financial assistance for utilities, rent, medical bills, or similar needs. Requests of this nature submitted through this form will not be addressed. This form is exclusively for applying to receive a counseling scholarship.

Insurance Information

Please provide documentation of your medical insurance, if applicable:
Do you have medical insurance?*

YesNo
Does your insurance cover any percentage of counseling services?*

YesNo
Proof of insurance*

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Are you seeking full or partial payment for your sessions?*

Full paymentPartial payment
Please describe the reason you are in need of financial assistance with counseling.*
Note: This form is not intended for requesting financial assistance for utilities, rent, medical bills, or similar needs. Requests of this nature submitted through this form will not be addressed. This form is exclusively for applying to receive a counseling scholarship.

Release of Information

Please fill out this release of information for King of Kings and The Core. This release of information allows King of Kings to evaluate your application in tandem with the counseling team. Some information may repeat from above.
Today's Date

MonthDayYear
Date
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Name of Counselor* (*hereby referred to as "Counselor")*
I hereby authorize and direct that Counselor (as identified above) will release information to and receive information from:

The CORE at King of Kings Church
11615 I St.
Omaha, NE 68137

The information requested is needed for the purpose of securing services and payment for counseling administered through The CORE at King of Kings Church.

I authorize CORE counselors to release information to King of Kings Church to secure sessions on my behalf. This authorization extends to the extent necessary to obtain payment for the services provided to me and includes authorization to release information about mental health and/or substance use with the express purpose of securing services, extension of services, or financial assistance for services.

Such disclosure shall be limited to the following specific information:
I hereby authorize disclosures on the following topics:

Medical: Discharge Summary, History, and PhysicalType Psychological: Evaluation, Diagnosis, Treatment Plan, Case NotesSocial: Social HistoryEducational: Transcripts and Test ResultsSubstance Abuse: Chemical Dependency Evaluation/Treatment Results/Treatment PlanAll Of The AboveOther
I understand that this authorization will expire one year from the signing of this Release of Information, or 30 days after my termination from treatment.

I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it will not have any effect on any actions they took before they received the revocation. Revocation of authorization may result in the termination of any further financial assistance in providing services from The CORE.

I understand that the individual/institution that receives the information described above may not be covered by federal privacy regulations and that the information may be re-disclosed publicly and no longer be protected by those regulations.

I understand the entities will not condition evaluation or treatment on whether I sign this authorization.

Warning: The confidentiality of this information is protected by Federal Law (42CFRII). No further disclosure of this information is allowed without the above-named person’s written consent specifying the release of this information in accordance with Federal regulations. YOU MAY REFUSE TO SIGN THIS RELEASE.
Signature
Approval for Benevolence Counseling sessions will be evaluated by a committee. King of Kings Benevolence Counseling Committee reserves the right to approve or deny any applications in part or in full.
Term & Conditions*

By submitting this I acknowledge and understand that all information is correct and I authorize King of Kings to release my information to contracted counselors. Additionally, I authorize counselors to update King of Kings with any pertinent medical information relating to my treatment in order to provide consistent feedback on my prognosis and progress in counseling. These updates between King of Kings and their contracted counselors are required to release payment to counselors. I understand that I am requesting financial assistance for counseling and that King of Kings has a committee that reviews these requests. If my application is approved, I authorize King of Kings and their contracted counselors to update my Benevolence Counseling records/status through the end of my approved sessions. I understand that King of Kings has a committee that reviews these inquiries, which may cause some delay in beginning treatment pending the approval or denial of this application.
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King of Kings Benevolence Counseling Application

Your Need

Insurance Information

Release of Information