• Parent / Guardian Application Form

    This form is for a parent or guardian who'd like to apply for Ahavas Chaya funding for a child (in the case where the applicant is above 18 and would like to fill out their own form, this form can be used as well).

  • 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 ›

  • Guidelines

  • Before we begin, please confirm that all the following requirements are met:

    1. The parent or guardian have explored every option of funding that is available to them (i.e. medical insurance, government funding)
    2. The parent or guardian will be responsible for a percentage of the provider's fee. This percentage will be determined upon approval of this application (Typically 25%).
    3. Ahavas Chaya only provides funding for psychologists, psychiatrists or licensed social workers.
    4. Finally, please be aware that the Ahavas Chaya only allocates funds for sessions that take place after our final approval.

    To learn more about eligibility, see our eligibility article.

  • Student Information

  • Student's date of birth*
     - -

  • Family Details

  • Marital status*

  • Contact Details

  • If a field isn't relevant or doesn't apply, write NA or leave it blank.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Family Reference

    Please provide a reference that is familiar with your family's financial situation.
  • Format: (000) 000-0000.

  • Financial Details

  • If a field isn't relevant or doesn't apply, write NA or leave it blank.

  • Health Insurance

  • Is the student covered by health insurance?*

  • Presenting Issues

  • Has the student received any formal diagnosis?*
  • Has this issue ever been treated by a mental health professional?*

  • Requested Funding

  • Please list below the mental health provider(s) for which you are requesting funding from the Ahavas Chaya.

  • Provider type*
  • Format: (000) 000-0000.
  • Have any discounts been negotiated with 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.

  • Any additional details

  • Confirmation & Signature

  • Date of Signature*
     - -
  • Should be Empty: