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

Services Available for Scholarship Support:

When clinically appropriate:

Initial evaluations and intake appointments
Ongoing clinical visits, including:
- Individual therapy
- Psychiatry
- Health coaching
- Dietetic services (when clinically indicated)
- Group therapy offerings (e.g., DBT, CBT, ACT, vocational skills)

At this time, Aurora, Foundations, Assessments, Team-Based Integrated Care Packages, and Consultations with Outside Providers are not available for scholarship support.

Name:

First NameLast Name

Date of Birth:

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

Race / Ethnicity (optional):

Employment Status:

Highest Level of Education (optional):

Primary mental health diagnosis/diagnoses:

How long have you been seeking mental health support?

Have you ever been hospitalized for mental health care?

If yes, please provide date(s)

Are you currently taking psychiatric medications?

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):

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?

Current Care: Are you currently seeing a therapist and/or psychiatrist:

If yes, please share provider name(s), frequency of visits (ex. monthly, weekly, etc.), and date(s) of last visit:

Insurance or cost barrier: Have you tried to access mental health care through insurance in the past 12 months:

Referral source (if any):

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:

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:

Checking or savings account

Total balances:

Investments or brokerage accounts

Total balances:

Trusts or other financial accounts

Total balances:

Real estate, including primary residence

Total balances:

Personal vehicles

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

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.

Date of Signature

Date

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