COMPASSIONATE
CARE FUND
APPLICATION
Individuals,
churches, and others have made donations to Upward Call/Shepherd’s Touch to
provide financial assistance for those who desire counseling that they
otherwise could not afford. This fund
enables us to offer a reduced fee when clients are unable to pay the full cost
of counseling. Please fill out the information
requested, as thoroughly as possible, and
return this form to our office.
Name____________________________________________________
Date________________
Address_______________________________________________________________________
Phone
numbers (house, cell, work)________________________________________________
Income (total household) Please provide proof of income, i.e.
paystub, W-2 information, unemployment information
______$0-$10,000 ______$10,001-$20,000 ______$20,001-&30,000
______$30,001-$40,000 ______$40,001-$50,000 ______$50,001 & over
How many adults are
living in your household?__________ How
many children?___________
Are there specific
circumstances affecting your ability to pay for counseling that we should
consider?
_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Insurance
Do you have health
insurance? YES______ NO______
If YES, please cal1 the 800 number on the back of your insurance
card and ask if you have any benefits for mental health care. If you have coverage, they will tell you what
those benefits are. Please call the
office manager at (717)-656-4834 to discuss the next step.
Church
What church,
religious or community organization do you attend?_________________________
They may provide full
or partial financial assistance for sessions.
Are you willing to contact them?
YES______ NO______ If “yes”, please
contact them.
If they are willing
to help, please provide the name of contact person and how they are willing to
help: _________________________________________________________________________
EAP
Many businesses have
an EAP (Employee Assistance Program), in which they pay for counseling for
their employees. Please contact your employer to see of they have an EAP
Program.
Work
Address__________________________________________________________________
Work Phone
Number____________________________________________________________
Other
Resources
A close friend or relative
may be willing to help cover all or part of the cost of your visits. Please list person to be billed:
Name:______________________________________
Phone:____________________________
Address:______________________________________________________________________
How much money are you able to invest for each counseling
session?___________________
By your signature,
you are agreeing that all of the above information is true and that you consent
for us to contact those you have approved.
Signature:________________________________________________
Date:________________
After review of this
application we will contact you. Your adjustment fee will be for 3
sessions, after which another review will take place.
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OFFICE USE ONLY:
Approved fee amount____________