Financial Assistance Application
For patients that have already registered.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently have insurance?
*
Yes
No
Insurance Information
*
Parent/guardian name
*
First Name
Last Name
Parent/guardian Email
*
example@example.com
Parent/guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Number of people living in your household
*
Are you the primary financial provider for your household?
*
Yes
No
Are any other household members currently receiving mental‑health services?
*
Yes
No
Total monthly household income (before taxes)
*
Do you receive government assistance (SNAP, TANF, SSI, SSDI, WIC, etc.)
*
Yes
No
Please describe your current financial hardship and why you are requesting financial assistance.
I declare that the information provided above is true and correct.
*
Submit
Should be Empty: