First and Last Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address If you are undocumented or unhoused skip this section
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Submission
*
-
Month
-
Day
Year
Date
Clients may qualify for financial assistance if they, or someone in their household meets one or more of the following criteria:
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Income at or below the Poverty Line ($30000 per year for a family of four)
Medicaid Recipient
Receives SNAP Benefits (Food Stamps)
Enrolled In WIC (Kids food program)
Receives food assistance for Native Americans
Receives Emergency Housing Assistance
Holds a Section 8 Housing Voucher
Enrolled in Subsidized Rental Housing or Public Housing
Receives Home Ownership Vouchers
Receives Temporary Assistance for Needy Families (TANF)
Receives SSI (Supplemental Security Insurance)
Receives SSDI (Social Security Disability Insurance)
Is Undocumented/ Unhoused (With Appropriate Documentation)
Is staying with a qualifying individual who is willing to share documentation
If you are undocumented/ unhoused: if you are staying with someone who meets the qualifications and is willing to share these documents- Please attach it to the file
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TITLE THE DOCUMENTS: FIRST NAME LAST NAME Ex: Jane Doe
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If you are undocumented and no one in your home qualifies/is unwilling to provide the documentation, or you are currently unhoused- please select this box
Check This box if this applies to you
If the above question applies to you, please upload pictures or scan documents that provide documentation of the boxes selected above
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TITLE THE DOCUMENTS: FIRST NAME LAST NAME Ex: Jane Doe
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By checking the box below you are agreeing to understanding the following: Financial Assistance form will be submitted and reviewed for approval. Once approved, you'll be contacted to schedule an appointment with a therapist with openings, in accordance to our financial assistance sliding scale. We can not guarantee the therapist of your choice has openings at the time of your application. If this is the case, you'll be offered other therapists who may openings. Financial Assistance:$5 per session for individuals currently at $0 income or on Medicaid. $15 per session for individuals qualifying for two or more assistance programs. $30 per session for individuals qualifying for one eligible service (excluding Medicaid). Financial assistance is capped at $30 per session. Session Policy/Renewal: Clients who are working with LPC, LSW, LCPC. LCSW level clinicians are initially approved for 24 sessions. After this period, re-approval is required for an additional 12 sessions, with a $5 increase in financial assistance. Clients may continue to seek re-approval in 12-session increments, depending on financial need and therapist availability. If a client is seeing a LPC, LSW, LCPC, LCSW clinician and would like to transfer to a masters level intern following the 24 sessions or follow the 12 session re-approval; the client’s rate will stay the same as it was for the previous clinician and is transferred to an intern with no session limit. If the client would like to see a masters level intern, the above payment scale applies however there is no session limit.
*
I understand and agree to the above policy
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