MH² Patient Access Scholarship Fund Application

MH² Patient Access Scholarship Fund Application
The purpose of this application is to help MH² understand your financial, clinical, and personal circumstances in order to determine eligibility for partial scholarship support. Completion of this application does not guarantee an award. Scholarships are needs-based and intended to reduce—rather than fully eliminate—the cost of care. All approved recipients are responsible for a patient copay, determined using Federal Poverty Level (FPL)–based guidelines. All information provided will be kept confidential and reviewed only by authorized MH² staff and Scholarship Committee members.

Who is Eligible?

Patients must:
- Be seeking or appropriate for MH² services
- Demonstrate financial need
- Have household income ≤ 400% FPL, no significant assets, and
  inconsistent/unavailable external financial support
- Be clinically appropriate for outpatient integrated care
- Be willing and able to participate in recommended treatment
- Reside in MA, VT, or FL during care
Part 1: Demographics

Tracking this information helps MH² report diversity and equity metrics. Individual responses are never shared with donors or external parties in an identifiable manner.
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Gender Identity*
Black / African AmericanHispanic / LatinoWhite / CaucasianAsianNative Hawaiian or Other Pacific IslanderIndigenous / Native AmericanOther
Full-timePart-timeStudentUnemployedDisabled
High school or equivalentSome college, no degreeTechnical/vocational certificateAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate/Professional Degree
Part 2: Mental Health & Medical Background
Primary mental health diagnosis/diagnoses:*
How long have you been seeking mental health support?*
YesNo
If yes, please provide date(s)*
YesNo
If yes, please list*
Services Requested: What MH² services are you hoping to access through this scholarship? (This does not replace a clinical evaluation and does not guarantee treatment)*
Other medical conditions (if any):
Part 3: Personal Experience, Readiness, and Goals
Your story: Please describe your current mental health and/or medical challenges and how they impact your daily life:*

0/300
Readiness for change:*
MH² takes a whole-person approach that may include nutrition and lifestyle changes. On a scale of 1–10, how ready do you feel to actively participate in such interventions?
Main Goal: What is the primary outcome you hope to achieve through participation in the MH² program?*
Part 4: Access to Care and Service Fit
YesNo
If yes, please share provider name(s), frequency of visits (ex. monthly, weekly, etc.), and date(s) of last visit:*
Yes, I am currently engaged with mental health care that is covered by my insuranceYes, but services were denied or not coveredYes, but copays or deductibles were too highNo, I have not tried to access care through insurance in the last 12 monthsNo, I am currently uninsured
Referral source (if any):
Part 5: Financial Information & Verification

MH² uses a needs-based review process similar to public benefit and financial aid programs. In most cases, this includes verification of income and certain assets for the applicant and, when relevant, family resources. MH² recognizes that financial situations vary and allows for consideration of extenuating circumstances when standard documentation is not available.
Please describe your current living circumstances, including who you are living with and how your housing is paid for (e.g., rent, mortgage, family support, housing assistance, or other arrangements).*
Number of people in your household (including you):*
Income: What was your total annual income for the past two years?*
2025
2024
Please provide income documentation for yourself and for family members listed above.
You may submit:
☐ Most recent federal tax return (Form 1040)
☐ Recent pay stubs or employer income verification
☐ Social Security or disability benefit letters (SSI / SSDI)
☐ Unemployment or other benefit documentation
Required Documentation for Income Verification:*

Cancelof
Asset Verification
We may ask for information about significant financial assets to help us fairly allocate limited funds. Do you currently have any of the following? Please provide balances and documentation (last statement available) for those that are applicable:
YesNo
Total balances:*
YesNo
Total balances:*
YesNo
Total balances:*
YesNo
Total balances:*
YesNo
Year/Make/Model, loan balance (if any):*
Last available statements for the above-mentioned assets:*

Primary homes, personal vehicle(s), and disability-related or restricted funds are reviewed with discretion and are not automatically disqualifying
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Family or Other Support: Please briefly describe any financial, housing, medical, or caregiving support you receive from family or others. Please specify all funds received from family over the past year, or any payments they make on your behalf, such as rent, utilities, medical co-pays, etc.*
Extenuating Circumstances: If you cannot provide any of the documentation requested above due to safety concerns, estrangement, lack of access, or other complex circumstances, please explain here. These situations are reviewed case by case and do not automatically disqualify you.*
Your Expected Contribution: How much could you reasonably afford to pay per session:*
This helps us determine your copay but does not guarantee a specific amount
Terms of the Scholarship

-Scholarships provide partial financial assistance only. Full scholarships are not offered.
-All approved patients are responsible for a copay, based on income guidelines and listed in the award notice.
-Scholarships cover approved services for a set period. Renewals depend on need, engagement, and available funds.
-Three late cancellations or no-shows may result in loss of the scholarship, except for emergencies.
-Participation may include completing surveys or labs to help MH² evaluate outcomes. Results are shared only in aggregate.
-You must live in Massachusetts, Vermont, or Florida during participation.
-All information is kept confidential and used only for care coordination and program administration.
Certification: I confirm that the information provided is true and complete to the best of my knowledge. I understand that missing or inaccurate information may affect eligibility.*

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MH² Patient Access Scholarship Fund Application

Part 1: Demographics

Part 2: Mental Health & Medical Background

Part 3: Personal Experience, Readiness, and Goals

Part 4: Access to Care and Service Fit

Part 5: Financial Information & Verification

Terms of the Scholarship