Jean Coldsmith Impact Grant

Jean Coldsmith Impact Grant: Financial Hardship Application

The Jean Coldsmith Impact Grant allows students to access mental health services who would not otherwise be able to. Qualifying students have a mental health need as assessed by a school social worker (grief, trauma, crisis, etc.) and financial means to pay for services. This financial hardship application is available for students who have insurance but still face significant barriers to accessing care. For example, they may have maxed out support through insurance but are still in crisis, they may have Medicaid but providers in town do not have Medicaid spaces available or they may have an extenuating financial circumstance that makes it difficult to meet copays.
Recommender's Name*

First NameLast Name
Recommender's Email*
example@example.com
Student's WISER ID*
Student's Full Name*

First NameLast Name
Please describe the type of services this student requires and the expected duration of treatment.*
Does this student have insurance? If so, what kind?*
YesNoI'm not sure
YesNo
YesNo
Family Information

This part of the application will request financial information and family information. It is required as part of the financial hardship application.
Annual Household Income*
How many adults reside in the household?*
How many children reside in the household?*
Please describe any extenuating financial circumstances that may affect this family. Some examples include: rent more than 50% of household income, sick or injured family member, loss of housing, unpaid medical debt, etc.*
Should be Empty:

Jean Coldsmith Impact Grant: Financial Hardship Application