Sweet Deeds Application for Assistance

Sweet Deeds Application for Assistance
Welcome! Sweet Deeds Foundation works to increase access to quality mental health by reducing financial barriers.

Through a collaboration between like-minded therapists, nonprofits, and donors, we offer significantly discounted rates and financial assistance for those who would otherwise be priced out.

Things to Know

Use this form to apply for financial assistance towards the cost of therapy or to apply for additional sessions.
- To be eligible, you must be referred by a Sweet Deeds therapist OR be a current member or client of one of our official partners.
- Funds may only be applied to the cost of therapy with our approved therapists. Funds are paid to the therapist, not the client, for therapy sessions.
- Finanical assistance is for self-pay clients. Those using insurance or whose cost of therapy is being covered by another organization aren't eligible.
- To qualify, your total household income needs to fall within the ranges listed below.
Number in Household / Income Threshold

1 person / $37,650
2 persons / $51,100
3 persons / $64,550
4 persons / $78,000
5 persons / $91,450
6 persons / $104,900
7 persons / $118,350
8 persons / $131,800

Based on 2024 HHS Poverty Guidelines

Privacy

We take your privacy seriously. Your information will be held confidentially and used solely to process your application.

Disclaimer

This form is adminstered by Sweet Deeds Foundation. Sweet Deeds is not a medical provider; information is used solely to determine eligibility for financial assistance.
Applicant Information:
Have you previously received financial assistance from Sweet Deeds?*

No, I've never received financial assistance from Sweet Deeds.Yes, I've previously received assistance from Sweet Deeds and am applying for additional sessions.
Full Name*

PrefixFirst NameLast Name
Mobile No. :*
E-mail :*
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
US counties
Who are you applying for?*

SelfFamily Member (e.g. child)
Name of Family Member(s) You're Applying for:
Household Size. Your household will generally include any dependents or individuals living in your household.
If you are over 18 but claimed as a dependent by your parents/guardians, please provide the household size and income of your parents/guardians.
Household Information. Please list ALL individuals living in your household, including yourself, using this format: Name / Age / Relationship to You*
Ex. Mike / 35 / Self
Referral Information
If you were referred by a therapist, please indicate their name. Referring therapists must be a part of the Sweet Deeds Network. Write N/A if not applicable. *
Are you a member of one of our partner organizations or churches? *
Application Questionnaire
We'd like to get a sense of who you are and what your story is. Could you tell us a little bit about yourself? *
Could you describe why you are seeking therapy? Do you have any prior experience with therapy? *
Why would you like to continue therapy? *
Have there been any changes to your financial situation since you first applied? (e.g. changes in employment, income, expenses, etc)*
Are you currently employed?

Yes, I have a full-time job.Yes, I have a part-time job.No, I'm not employed, but I'm receiving unemployment benefits.No, I'm not employed and won't be receiving unemployment benefits.
If currently unemployed, what was your total income over the past 12 consecutive months? *
What is your total household income BEFORE taxes per year? Please include all wages, spouse's salary, unemployment, and other forms of income such as alimony, child support, Social Security, housing allowance, etc.*
Income Eligibility*

My total household income falls within the thresholds listed for my household size.My total household income does NOT fall within the thresholds for my household size. However, I have extenuating circumstances which I've explained below.
Will you be receiving any additional sources of financial assistance for therapy?*
If yes, please list source and amount or write N/A (eg. Church Benevolence, $500 total)
Insurance
If you have insurance coverage, we encourage you to see if your plan provides any out-of-network benefits, as these can be substantial.
Income Verification - New Applicants

YOU MUST UPLOAD ONE of the following proofs of income: W2, 1040, OR 2 months bank statements. If you don't have any of these documents, choose "Other" and provide a brief explanation.
Which form will you submit? Choose one.*

W210402 Months Bank StatementsOther - I've provided an explanation below.
Income Verification - Returning Applicants

If you've previously received a Sweet Deeds Scholarship, you do NOT need to submit income verification UNLESS your financial situation has changed.
Cancelof
Comments or Questions. Is there anything else you'd like to share with us? If applicable, use this box to help us better understand any extenuating financial circumstances you may have.
Demographic Information

The following questions help us understand who we have the privilege of serving and improve access to our services. Your responses are confidential. You may choose ‘Prefer not to answer’ to any question. Applicant refers to the individual who will receive services."
In what county does the applicant currently reside? *
Gender Identity of Applicant*
Race / Ethnicity of Applicant (Select all that apply)*

American Indian or Alaska NativeAsian / Pacific IslanderBlack / African AmericanHispanic / LatinoWhite / CaucasianNative American / IndigenousPrefer not to answer
Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
Should be Empty:

Sweet Deeds Application for Assistance

Applicant Information:

Referral Information

Application Questionnaire

Income Verification - New Applicants

Income Verification - Returning Applicants

Demographic Information

Applicant's E-Signature