Thompson Beck Memorial Fund Application

In honor of Chloe Thompson and Alicia Beck, The Thompson Beck Memorial Fund was created to serve individuals in our community by helping them rediscover their own sovereign soul through equitable access to mental health care regardless of financial circumstance, reducing stigma in asking for help, and caring for the whole person by considering all circumstances that may make affording therapy a challenge.

In addition to this, we are dedicated to making mental health care accessible in our community and strive to do our part in addressing systemic issues that decrease access to care.

Scholarship Details

Our scholarship includes 12 free or financially assisted sessions that must be used within 4 months. If you are able to afford to pay a small sliding scale rate less than $45 per session, TBMF will cover the remaining balance. At this time, TBMF is only able to provide financial assistance for counseling services at Sovereign Soul Counseling.

There is no shame in needing financial assistance to afford mental health care. 
We are happy to help where we can!

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Email *
Who is completing this form? *
First and last name of the person who will be receiving services
 *
Address (Street, city, state, and zip code) *
Have you applied for a scholarship through Thompson Beck Memorial Fund before? *
Are you a current client at Sovereign Soul Counseling? *
If you are a current client at SSC, who is your therapist?
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Please list all household members, including those under the age of 18, and your relationship to them. 

*Household includes anyone living in the same dwelling as you.
 *
What is your individual annual income?

Please note, the amount you indicate in this question does not disqualify you for assistance. We will not make a determination for assistance on this question alone. 
 *
Do you receive financial support from anyone else in your life? (i.e. someone else helps pays your individual bills) *
Do you share financial responsibilities with anyone in your household? (i.e. you split mortgage or rent costs, utilities, or other shared expenses) *
Are you currently receiving annual unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' disability payments, survivor benefits, pension or retirement income?  *
Do you currently receive income from any of the following sources: interest; dividends; royalties; income from rental properties, estates and trusts; alimony; child support; assistance from outside the household; or other miscellaneous sources? *
How much do you pay in monthly expenses (include monthly bills, debt payments, business expenses, maintenance costs, regular leisure/self-care costs, etc.)? *
Are you currently employed? *
Are you currently working but have many absences or call outs due to mental health or physical illnesses or injuries? *
Have you recently been laid off from your job? *
Are you currently a caregiver for someone in your life who is elderly, ill, disabled, has complex medical needs, or whom is otherwise dependent on you for care? 

(Do not include minor children in your household unless they also fall into an aforementioned category)
 *
Are you currently struggling with substance use? *
Are you currently struggling with compulsive spending? *
Are you currently struggling with gambling? *
Do you have health insurance that pays for mental health counseling?

*Answering this question will not disqualify you for assistance*
 *
If you answered "yes" (or any variation of "yes") to the previous question, who is your insurance provider?
Are you a veteran or active duty service member? *
Are you a first responder? *
Are you a minor, or completing this form for a minor, who has expressed any suicidal ideation?  *
Do you have Medicaid? *
Please tell us a little more about you and your life circumstances right now that make affording therapy challenging. *
We operate on an honor basis. We will not ask you to provide proof of income or other life circumstances as we do not want the experience of asking for financial assistance to feel shameful.  *
Required
As part of our application, we would like to speak with you personally to understand you and your needs better. 

This is not a formal interview - we want to honor our value of caring for the whole person and we recognize that completing a form does not necessarily capture "you". 
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Required
Thank you for taking the time to complete this application! 

We will be in contact with you as soon as possible!
If you have any further questions, please contact us at info@sovsoulcounseling.com or call/text 720-248-7071
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