Financial Discount Form
To be completed by potential or current clients who would like to be considered for free or discounted mental health services.
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any diagnoses that your child has or that have been discussed with you by any professional. If none, reply "NA."
Is your child already a client with ACTION, Inc?
Yes
No
Do you have insurance currently?
Yes, Medicaid
Yes, Commercial
No
I am working on applying for insurance
Reason for requesting a financial discount
Monthly Income
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: