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.
Sign in to Google to save your progress. Learn more
Email *
Client Name: *
Client Date of Birth *
MM
/
DD
/
YYYY
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?
MM
/
DD
/
YYYY
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 info@austingrief.org.
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 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Austin Center for Grief and Loss.

Does this form look suspicious? Report