Therapy Assistance Application Patient Section

Therapy Assistance Application Patient Section

Keepers of the Flame® Foundation
Patient Section

Client Eligibility: 1) A Breast Cancer Patient in Georgia 2) Require Financial Assistance to Therapy Note to patient: A maximum of 5 sessions can be approved at a time; you may choose less than that, and/or you may also reapply for additional sessions after completion of those that are approved.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you a breast cancer patient?*
Age*
Annual Household Income:*
Total # People in Household:*
Number of Sessions Requested:*
Brief explanation of how this program would benefit you: Ex: Three-year breast cancer survivor experiencing anxiety*
Preferred Counseling Partner*
You can learn more about our Counseling Partners on our website (www.togetherweweather.org/therapy). Already have a therapist not on this list? No problem. Select 'Other' and enter their contact information below. We'll connect and see if they'll participate.
NOTE: If you do not have a preference for a Preferred Counseling Partner, we recommend that you pick one of our current partners since they are already familiar with the process. You can learn more about them on our website: www.togetherweweather.org/therapy
Name of Preferred Counselor's Business if selected 'Other'
If you selected 'Other' for Preferred Counseling partner, enter their business name here, and we'll connect to see if they'll participate.
Counselor's Phone Number
Counselor's POC email
example@example.com
Consent:

By signing below, I hereby authorize Keepers of the Flame® Foundation, a not-for-profit corporation, to share any and all information provided in this application (including PHI) to their grant providers, counseling partners, and third-party service providers associated with this digital application platform (Jotform) in order to assess eligibility, provide assistance, process invoices on my behalf, and evaluate program effectiveness. I understand that in granting permission with my signature below, Keepers of the Flame® Foundation will be able to integrate form responses into their GoogleDrive and GoogleSheets in order to effectively run the program. I understand that these person(s)/organization(s) above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information provided on this application. I understand that this application includes ALL of the items listed in it, and I consent for Keepers of the Flame® Foundation to use the information provided to act on my behalf. I further understand that the submission of this application does not guarantee assistance. I understand that Keepers of the Flame® Foundation will not review mental healthcare office notes or information shared with mental health professionals, nor will they have access to my medical health records. I also understand that Keepers of the Flame® will not cover any “no-shows” and that I will be subject to the “no-show policy” of the counseling center I choose to schedule with. I hereby release and hold harmless Keepers of the Flame® Foundation from any HIPAA or other legal issues that may arise from providing such third parties with access to such PHI data associated with the application intake and program enrollment. I further acknowledge that my participation in this program is voluntary. I hereby release Keepers of the Flame® Foundation, its board of directors, officers, volunteers, and any other third parties involved in running the program from any and all claims, demands, actions, liabilities and damages whatsoever by me or any third party in connection with my participation.

HIPPA WAIVER:

I give my permission for my mental health provider’s office to disclose my health records with Keepers of the Flame for the purpose of payment of treatment, and for program quality review. - - Keepers of the Flame will not review mental healthcare office notes or information shared with mental health professionals. The information gathered will be strictly used for payment purposes, and to evaluate the effectiveness of the program. Form of Disclosure: Electronic copy or access via a web-based portal Hard copy I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. This authorization to share my health information is valid from the date of the signature below until I decide to revoke this authorization. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: KEEPERS OF THE FLAME FOUNDATION INC 329 PURPLE PLUM DR RINCON, GA 31326 I understand that: In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I understand that I do not need to give any further permission for the information detailed to be shared with Keepers of the Flame. I understand by signing this document, it is not a guarantee of payment. I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
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