Stronger Together: Financial Assistance Application
The Chicago Lighthouse, under the "Stronger Together" initiative, is committed to ensuring access to mental health counseling services. Through this initiative, and for a limited time, we may be able to cover a portion of the attached out-of-pocket expenses. The following questions will help us understand your financial situation and determine your eligibility for financial assistance. By completing this questionnaire, you understand that funds may be available to help cover out-of-pocket costs for mental health services as part of this initiative but not guaranteed. Funding is limited and may be available from December 1, 2024 to November 30, 2026 or until funds are expended. Applicants are encouraged to apply early to take advantage of this support while funds last. Please note: you have 30 days from the date you receive an invoice to complete your application.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you solely responsible for the mental health out-of-pocket costs related to the care you receive at The Chicago Lighthouse?
*
Yes
No
Are you currently facing financial challenges that may make it difficult for you to cover out-of-pocket expenses for mental health services?
*
Yes
No
Have you recently experienced any of the following? (Check all that apply)
*
Job Loss
Medical Emergency
Significant Reduction in Income
Unexpected expenses (care repairs, home repair, etc)
Other
How would you rate your current financial stress level?
*
Low
Moderate
High
Are out of pocket mental health care expenses preventing you from accessing mental health support at The Chicago Lighthouse?
*
Yes
No
Would you like the Stronger Together initiative to cover your out-of-pocket expense?
*
Yes
No
Please Note: The signature field in this form may limit accessibility for screen readers. Instead, you can type your full name in the text box below as confirmation of your signature. Thank you for your understanding while we work with JotForm to improve the accessibility of their signature widget. If you are not using a screen reader, please skip this section and sign in the signature pad below.
Type Your Full Name
I affirm that the information provided is true and accurate. I understand this information will be used solely to determine eligibility for limited-time financial assistance through the Stronger Together initiative. I understand that by signing this document, I am requesting the assessment of my eligibility for financial assistance. I understand that funds are available to help cover out-of-pocket costs for mental health services as part of this initiative but not guaranteed and that funding is limited and may be available from December 1, 2024 to November 30, 2026 or until the funds last.
Submit
Submit
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