Site Logo

Forms

Financial Assistance Form

Community MindEd's Therapy Scholarship Program provides financial assistance for individuals and families seeking mental health services who might not otherwise be able to access care. Our goal is to make therapy more accessible, equitable, and community-centered.

1. Basic Contact Information

This information helps us communicate with you and process your application.

Preferred Method of Communication*

2. Insurance Status

This helps us understand how to best coordinate assistance. We do not need copies of your insurance card or full policy details.

Do you currently have active health insurance?*

Are you currently using insurance for therapy?*

Do you qualify for Medicaid?*

3. Financial Overview

Your responses help us assess financial needs respectfully. No proof of income is required at this stage.

Employment Status*

Approximate Household Income (per year)*

Are you experiencing financial barriers to accessing mental health care?*

Have you had any changes in life circumstances (e.g., job loss, major expenses, illness)?*

4. Reason for Seeking a Scholarship

5. How Did You Hear About the Scholarship?

6. Therapy Preferences

This section helps us match you with an appropriate provider.

Do you currently have a therapist in mind?*

Are you open to us sharing your information with available providers so that you may be accepted by one of our partnered therapists?*

Therapy type needed (optional, select all that apply)

7. Agreement to Participation Expectations

By submitting this application, you acknowledge and agree to the following:

Signature

Optional Questions

These are voluntary and help us better understand how our program reaches the community.

Have you previously received assistance from Community MindEd?

Are you currently accessing other community support services?