Psychological Funding Application

Psychological Funding Application

This form is part of the Mental Health Initiative to provide financial assistance for psychologist services to individuals with spina bifida and/or hydrocephalus and their parents/primary caregivers.
Personal Information

.
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Health and Medical Information

Please provide details about your health condition and medical needs.
Name of the person with spina bifida and/or hydrocephalus*

First NameLast Name
Briefly describe your, or your child's, medical condition (spina bifida, hydrocephalus, or both) and how it affects your mental health.*
Psychologist Service Details

Information about the psychologist services you seek funding for.
2. Consent to Release Information
I,Full Name* give permission to SBHANA to contact my psychologist or mental health therapist regarding appointment verification and payment processing for services funded through the SBHANA Mental Health Initiative.
Name of the Psychologist or Clinic*
Location of the Psychologist or Clinic (City within Alberta, or online)*
Phone Number of the Psychologist or Clinic*
Please enter a valid phone number.Format: (000) 000-0000.
Email of Psychologist or Clinic*
example@example.com
Funding Details: Maximum of $2,000 per family, per fiscal year (February 1 – January 31). Funding is available after all other insurance or government support have been accessed. It may be used to cover co-pays or uncovered balances. Payment will be made directly to the Psychologist for approved applications by SBHANA.

Please specify your funding needs.
Private insuranceFSCD or other government programOtherNo coverage
What is your per session cost (after any insurance or benefits payments are made)? *
Requested Funding Amount *
Additional Information

Any other relevant information or special considerations.
Please provide any additional comments or information that may support your application.
Signature*

Clear
Should be Empty:

Psychological Funding Application

Personal Information

Health and Medical Information

Psychologist Service Details

Additional Information