Stephen's Rise and Grind Mental Health Financial Assistance Application 
This form is to be completed by the referring professional. 
Email *
Email *
Therapist/Counselor First Name *
Therapist/Counselor Last Name *
Therapist/Counselor Phone Number *
Preferred Method of Contact  *
Name and address of treatment facility where applicant currently receives or plans to receive treatment.


*
Reason(s) for qualifying for financial assistance.
*
What is the estimated time that financial assistance will be needed? 
*
What is the total estimated amount of financial assistance that the applicant will need?
*
Yearly income level of applicant.
*
Household size of applicant (including applicant).
*
How long has applicant been in treatment?
*
Current services per month. 
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Recommended services per month. 
*
Applicant's diagnosis.
By checking "I agree", the referring therapist/counselor attests that there is no discrimination of the referral of the applicant on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.*

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