Application Form for Schools/Liaisons

Please note: This form is for schools or family liaisons only.
If you're a parent, please visit our parent 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 ›

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

1. The student must have legitimate need for professional mental health intervention.
   
   
2. The paren or guardian has explored every option of funding that is available to them (i.e. medical insurance, government funding)
   
   
3. The Liason feels that therapy is the most effective medium to address student's issues (as opposed to mentoring, changing environment, etc.)
   
   
4. The student will be seen by a mental health provider that is qualified to treat the presenting issues. Ahavas Chaya only provides funding for psychologists, psychiatrists or licensed social workers.
   
   
   
5. The Liason agrees to actively case manage the student's progress by maintaining contact with the student and (when necessary) parents' and mental health provider. If a student has an issue with the professional they are seeing, the school should contact us.
   
   
   
6. 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%).
   
   
7. 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.

Please enter the student's name exactly as it was entered on the parent's application form. If that form has not been submitted yet, please direct the parents to do so.

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