Agreement and Signature: I understand that the information provided in this application is confidential and will be used solely for the purpose of determining my eligibility for Balance Relief for mental health services. I certify that the information provided is accurate and complete to the best of my knowledge. I understand that I may be required to provide supporting documentation to verify the information provided in this application.
By typing my name below, I acknowledge that I have read and agree to the terms and conditions outlined in this application. I acknowledge and understand that the statement above may be used for grant reporting purposes, however, identifying information will be withheld and remain confidential.