Financial Assistance Application Form

Financial Assistance Application

To Be Completed by Applicant or Parent/Guardian of Applicant
Name of person to receive services*

First NameLast Name
Male / Female

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Parent/Caregiver name if client is a minor*
Is applicant currently covered by a health insurance policy?*

YesNo
If yes, list Insurance Company Name and Deductible/Out of Pocket Maximum *
Are you currently receiving therapy services?*

YesNo
If yes, please list practice and/or providers name*
If you currently owe a balance, please select estimated amount of balance owed

$10.00-$100.00$101.00-$250.00$251.00-$400.00Over $400.00N/A
If you are NOT currently receiving therapy services but HAVE identified a practice or clinician you wish to see, please list practice and/or provider name*
By continuing the application, I acknowledge and understand the following:

If granted scholarship funding assistance for services, I will need to fill out and sign an Release of Information for Enduring Hope Inc member to identified service provider for on my behalf for billing and payment purposes.
I have read the above disclosure and agree. Please note, to receive scholarship funding, applicant must agree to proceed with application finalization.*

Yes, I understand and agree
In one paragraph, please briefly describe counseling needs. *
Please make a brief statement describing your need of financial assistance. *
If employed, what is your occupation / job title? *
What is partner or other responsible party's occupation? *

What is the combined/total annual household income: Check the appropriate box.

	Under $20,000	$20,000-$30,000	$30,000-$40,000	$40,000 and Up
Income

The amount of assistance is based off a rolling tier.

The items listed below are to be transferred from your 1040: (Includes spouse's information is applicable).
Number of Dependents*
Line 6C on 1040, Line 5on 1040 EZ or Line 6C on 1040A.
Adjusted Gross Income*
Line 37 on 1040, Line 4 on 1040 EZ or Line 21 on 1040 A.
Total Income*
Line 22 on 1040 or Line 15 on 1040 A.
List Special or Change in Financial Circumstances (If Any)
By signing this document, I agree to the following

-The information provided in this application is accurate.

-The number of sessions provided by the scholarship is limited and it is up to applicant to keep track of session's used/remaining and to reapply for additional assistance if more sessions are applicant cannot take over cost of payment.

-Submitting this application and accepting funding ackowledges payment will be rendered directly to service provider on behalf of client at the rate approved and set forth by Enduring Hope Inc scholarship fund. If current or desired service provider does not agree to accept the rate set by Enduring Hope Inc, applicant has the option to: forfeit assistance, change service providers or appeal directly to service provider for his/her/their acceptance of Enduring Hope's reimbursement rate.
Applicant / Parent or Guardian Name *

First NameLast Name
Applicant / Parent or Guardian Signature*

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Please Note: Financial assistance is not guaranteed. It will be determined based on the viability of your application. Assistance will be given based on the availability of funds and level of need.

This application is confidential. The information on the form will not be disseminated.

Our financial assistance committee will meet once a month to allocate funds. the committee will divvy up the Financial Assistance funds received from Fundraising efforts until they are diminished.

We will notify applicants of the award amount within 2-4 weeks.

Need is the most important priority for the Financial Assistance Program.

My Products

Enduring Hope Application Fee Product Image

Enduring Hope Application FeeIf affordability of application fee is a problem, please contact organization directly.

$25.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Methods

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