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Information & Registration |
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MY HEALING PLACE APPLICATION FOR CARE ASSISTANCE MY HEALING PLACE is a non-profit organization that exists to assist persons who have experienced a significant and/or traumatic loss in moving toward healing. It is the desire of the staff of MY HEALING PLACE for all who seek assistance to be served, regardless of ability to pay.
MY HEALING PLACE is funded by fees paid for therapy services, private donations, monies raised at primary fundraisers and grant funding. Therefore we ask persons who have the ability to pay the stated fees do so at the close of each session, unless other payment arrangements have been made in advance. For those unable to pay the stated fees for therapy services MY HEALING PLACE asks that you complete the following application for care assistance. This application will allow us to respond to those who are most in need, as funding is available for us to do so.
In addition to the Client Information Form, please submit this completed application by email, regular mail, or in person prior to your first appointment at MY HEALING PLACE. After the application is reviewed you will receive a phone call or email (as you may indicate) to inform you of the arrangement we are able to make in regard to your fees for service. Doing this in advance will allow the staff to better serve you upon your arrival for therapy. Please be assured that all financial information on this form will be kept confidential.
CLIENT/s NAME: _________________________________ , _______________________________
Parent/Guardian’s Name ____________________________________ (If client is child under 18 years of age)
MAILING ADDRESS: ____________________________________________________________
EMAIL: ____________________________________________
HOME TELEPHONE # _________________________________
OTHER CONTACT # ___________________________________
DATE OF BIRTH ________________________
OCCUPATION: _________________________________________________________________
PLACE OF EMPLOYMENT:________________________________________________________ (If you are not currently employed, please indicate when and where you were last employed – and the circumstances of the termination of your job.) ______________________________________________________________________________
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______________________________________________________________________________ DO YOU CURRENTLY HAVE INSURANCE COVERING MENTAL HEALTH SERVICES? IF SO, PLEASE EXPLAIN THE COVERAGE YOU HAVE FOR COUNSELING SERVICES. ______________________________________________________________________________
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PLEASE NOTE YOUR ANNUAL INCOME (THE AMOUNT YOU TAKE HOME) BY PLACING A MARK BESIDE THE CORRECT BLANK. My family earns an annual income of
____ Less than $16,000 per year
____ $16,000-22,000 per year
____ $23,000-30,000 per year
It is the philosophy of MY HEALING PLACE that all persons may benefit from therapy services when there is commitment, both personal and financial. to the process of healing. Therefore we ask all persons to pay something toward their treatment. The following are our standard fees for therapy services. Based on knowledge of these fees and your own financial resources what do you believe you are able to pay?
Initial Session of Individual Therapy: $100 Initial Session of Family Therapy: $125 Initial Session of Group Therapy: $50
Each additional Individual Session: $70 Family Session $90 Group Session $25
Please complete the following statement of need. I request my ________________________therapy services be reduced to $________ for the initial (individual, family, or group) session and $_______ for each additional session. I understand this request will be reviewed in light of funds available for financial assistance and the number of requests at this time. Financial assistance is granted to those with the greatest need in the order applications for assistance are received. Further, I understand I will be contacted to discuss the outcome of this review prior to my first appointment. I wish to be contacted by (___phone or ____ email). I also understand this request will be reviewed periodically to determine if there is still a need for care assistance.
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FOR OFFICE USE ONLY Date Application is received: _________________
Signature of Receipt _____________________
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