The Austin Center for Grief and Loss Application for Care Assistance
Please complete the following application if you wish to discuss a reduced fee for your therapy services. Please be assured that all financial information on this form will be kept confidential.
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Email *
Client Name: *
Client Date of Birth *
Parent/Guardian Name (If client is under 18 years of age): *
Mailing Address (Street, City, State, Zip Code): *
Phone Number: *
Most recent place of employment: *
Occupation: *
Are you still employed here? *
If not, when did you leave?
My family earns an annual income of : *
*Please email a copy of the most recent tax return and/or pay stub(s) for each family member who is working outside the home to
Number of people in your household: *
Is there any other financial information that is important for us to know?
Please complete the following statement of need:
I request my ____________________(individual, family, or group) therapy services be reduced to $________ for the initial session. *
I request my fee be reduced to $_________for subsequent sessions (if applicable). *
I also understand, if approved, my session payments will be subsidized by the “Circle of Caring Fund.”  Due to limitations of this funding, I will receive a maximum of 10 sessions under this agreement.  I also understand that this request will be reviewed periodically to determine if there is still a need for care assistance.  At the close of my therapy sessions (up to 10 sessions) I may be referred to a support group, therapy group, or to another agency for additional services as needed.
Name and Initials of individual responsible for payment *
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