Promise Fund Recipient Application
By completing this form you certify that due to extreme financial/social hardship you are unable to pay for therapy services at this time and would like to be considered for acceptance as a Promise Fund client

                                                  Applications are submitted via the website for approval
                                                            If approved, client is given 8 or 12 sessions

                                                If client can pay a $30 copay, client will receive 12 sessions
                                                      If client is not able to pay, client will receive 8 sessions


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Email *
Name *
Are you able to pay a $30 copay? Please type YES, NO, or an amount you can pay at this time  *
Number of individuals in household(including self) *
Phone number
Please describe the nature of your hardship(ex. bankruptcy, divorce, disability, etc). If accepted, a team member will contact you to confirm waiver of fees. Please note- even if you are not accepted, you may be eligible for a reduced fee agreement. Please discuss with therapist during the initial consultation *
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