Parent / Guardian Form

Parent / Guardian Application Form

This form is for a parent or guardian who'd like to apply for Ahavas Chaya funding for a child.
Please note: This form is for the child's parent/guardian only.
If you're a school or liaison, please visit our liaison application page instead.

This is a detailed application. For your comfort, we recommend filling out this form on a desktop computer.

At any point you can click "Save and Continue later" to save your progress. You'll receive an email link which you can use to resume filling out this form later.

Got questions? Contact us ›

Contact Details
If a field isn't relevant or doesn't apply, write NA or leave it blank.
Father's phone
Father's email
Mother's phone
Mother's email
Home phone
Family Reference

Please provide a reference that is familiar with your family's financial situation.
Name of Reference*
How do you know them?*
Reference phone*
We'll contact them to confirm your details.

Health Insurance
Is the student covered by health insurance?*

YesNo
Insurance Name*
Policy type*
What coverage does your Health Insurance provide for Mental Health Services? (Please explain and provide any information regarding; out of network benefits, copays, deductibles etc.)*

Presenting Issues
Please describe in detail why your child is being referred for professional intervention, and in what way your child and family are being affected by this issue.*
Has the student received any formal diagnosis?*

YesNo
Diagnosis*
Which mental health provider gave the diagnosis?*
Has this issue ever been treated by a mental health professional?*

YesNo
Names of the professionals*

Requested Funding
Please list below the mental health provider(s) for which you are requesting funding from the Ahavas Chaya.
Provider name*
Provider type*

PsychologistPsychiatristSocial WorkerOther
Who referred you to them?*
Provider phone*
We may contact them to arrange case details.
Provider email*
We will email them to confirm case details.
Cost per Session*
in USD
Have any discounts been negotiated with the providers?

YesNo
Negotiation Details*
Anything else you'd like to tell us about the providers?

About the Approval Process
If a student is approved for funding, the mental health provider will receive direct email confirmation of Ahavas Chaya's responsibility to them.

Ahavas Chaya only approves several sessions at a time.
Additionally:
- Ahavas Chaya will not be responsible for any bills for which the provider did not receive email confirmation from us.
- Ahavas Chaya does not pay the provider until the family has paid its pre-arranged share.
- The Mental Health Provider bills should indicate parent's responsibilities and reflect the parent's payments.
- Ahavas Chaya is only responsible for bills submitted within 6 weeks of treatment.
- If provider did not receive our email notification, please have the school or liaison follow up with Ahavas Chaya. We cannot fund sessions that have not received direct approval from our office.

Confirmation & Signature
Agreement

I confirm that all the above information is correct and hereby give permission to Ahavas Chaya to provide payment towards my child's therapy and treatment. I understand that A.H. does not take responsibility for choosing a provider or for overseeing the quality of care and reserves the right to stop funding at any time for any reason. I understand and agree to all application requirements.
Legally Binding Signature

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Date of Signature*

MonthDayYear
Where should we email your copy of this document?*
Should be Empty:

Parent / Guardian Application Form