Client Hardship Escalation Request
If you are facing an urgent situation and need expedited review of a funding request, complete this form. We prioritize urgent situations and will do our best to respond within one to two business days. For immediate mental health crises please call or text 988.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Best Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Provider's Name (if applicable)
What is the urgent situation? (Check all that apply)
I have an appointment scheduled and funding has not yet been approved
My funding ran out and I have an upcoming appointment I cannot afford to miss
I have just experienced a significant financial crisis — job loss, medical emergency, housing instability
My child is in acute need of services and cost is the only barrier to starting
My provider has indicated they cannot continue services without payment
Other
Upcoming appointment date (if applicable)
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Month
-
Day
Year
Date
Please describe your situation briefly:
Signature
*
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: