The goal of this fund is to provide short-term mental health support for LGBTQIA+ individuals who are desiring LGBTQIA+ specific therapy with competent therapists. 

DEMOGRAPHICS: By using the fund, you allow the fund to collect this demographic information for grant purposes (all other sections remain confidential to the JR Team and individuals filling out this fund).

The information below is confidential and will not be shared or utilized for grant purposes. 

There can be high medical expenses associated with the queer community (HRT/IVF/Adoption fees), so we are asking you to subtract your medical expenses from your gross income to find your personal payment fee. Subtract two dollars from your co-pay for every dependent you have.

Single/One Income minus medical expenses	Copay Amount
0 - 20,000	$10
20,000 - 45,000	$20
45,000 - 70,000	$35
70,000 - 95,000	$60
95,000 - 120,000	$85

Married/Combined Income minus medical expenses	Copay Amount
0 - 40,000	$10
40,000 - 80,000	$20
80,000 - 120,000	$35
120,000 - 160,000	$60
160,000 - 200,000	$85

Treatment Plan: It is the responsibility of the therapist and the client to set realistic treatment goals within these limitations.

I attest that all information provided in my application is accurate, including my income and insurance status. I understand that if the information in my application changes, including enrollment in or eligibility to receive Medicaid, my scholarship will no longer be valid, as behavioral health services can be obtained through other financial options. I confirm that paying for therapy presents a significant financial burden for me, that my current insurance or lack of insurance is an impediment to adequate care, and that I am not able to pay for care. I understand that AspenOUT does not evaluate, endorse, or guarantee the services of any mental health provider participating in the Jack Raife Fund. AspenOUT does not schedule appointments; it provides financial assistance to licensed providers through HAT who participate in the program. I am responsible for selecting and planning with my chosen provider. If I am not comfortable with my therapist, I may contact HAT for help connecting with another provider.

The Jack Raife Fund (hereafter "the Fund") provides financial assistance only to cover the cost of mental health services provided by licensed, independent, third-party practitioners.

The Fund is not a provider of mental health care, counseling, or medical services. The Fund does not employ, supervise, or control the clinical judgment, methods, or treatment decisions of the therapists who receive payment through this program.

I, the Client, acknowledge and agree that the therapeutic relationship and all clinical decisions regarding my treatment, diagnosis, and progress are exclusively between me and my independent mental health professional.

I understand that:

• The Fund does not provide, recommend, or endorse any specific treatment method, modality, or outcome.
• The Fund has no liability or responsibility for the quality of care, professional conduct, negligence, errors, omissions, or any other actions taken by the therapist during or outside of treatment sessions.
• Any claims, disputes, or grievances regarding the clinical services received must be directed solely to the licensed therapist and/or their professional licensing board.

By accepting financial support from the Fund, I hereby release, waive, and forever discharge the Jack Raife Fund, including its officers, directors, employees, and agents, from any and all liability, claims, demands, damages, and causes of action arising out of or related to the therapeutic services I receive.

This release covers all liability, known or unknown, arising from or connected to the delivery, non-delivery, or cessation of the clinical services, including but not limited to, any unsatisfactory therapeutic outcomes, clinical malpractice, or breach of confidentiality by the independent practitioner.

I affirm that it is my sole responsibility to review the credentials, licensing status, and professional qualifications of the therapist I choose to engage with, and to ensure they meet my individual needs and standards.

a. Clinical Liability: The Provider is solely responsible for all aspects of the clinical services provided. The Provider shall bear all liability arising from or related to the Services, including but not limited to, claims of professional negligence, malpractice, breach of confidentiality, or any act or omission related to the treatment of Clients.

b. Required Insurance: The Provider warrants that they hold and will continuously maintain, at their sole expense, Professional Liability Insurance (Malpractice) with coverage limits of not less than $1,000,000 per occurrence and $5,000,000 aggregate. The Provider shall furnish proof of current coverage upon request by the Fund.

c. Indemnification: The Provider agrees to indemnify, defend, and hold harmless the Fund, its officers, directors, employees, and agents from and against any and all claims, damages, liabilities, costs, and expenses (including reasonable attorneys' fees) arising from or related to: i. The Provider's clinical services, acts, or omissions. ii. The Provider's failure to maintain required licenses or professional liability insurance. iii. Any breach of this Agreement, including compliance with HIPAA and confidentiality laws.

5. No Guarantees and Potential Risks 

No Guarantees. l understand that psychotherapy is not an exact science, and the results of therapy cannot be guaranteed. My therapeutic outcome depends largely on my willingness to participate fully in the process both during and between sessions.

Potential Risks. I understand that therapy may involve discussing unpleasant aspects of my life and can sometimes lead to uncomfortable emotions (e.g., anxiety, sadness, frustration, relationship strain) before improvement is seen. I understand that AspenOUT does not evaluate, endorse, or vouch for the services of mental health providers that participate in the Jack Raife Fund. I also acknowledge that AspenOUT does not schedule appointments; it only provides funds to providers through HAT who participate in the Jack Raife Fund program and provide financial assistance for therapeutic services with currently licensed mental health providers. It is my responsibility to investigate my chosen provider, determine whether it is a good fit, and schedule appointments with the selected provider. If I am not comfortable with my therapist, I can reach out to HAT to help connect me with another therapist.