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Welcome to the Access to Therapy Initiative Therapy Funding Application

Thank you for your interest in our therapy funding program. Our mission is to provide access to mental health services for individuals who face financial barriers to receiving care. This application form is the first step in the process to determine your eligibility for funding support. Please answer all questions truthfully and to the best of your ability.

Once you submit your application, it will be reviewed by our team, and you will be contacted about the next steps. Please note that funding is contingent upon several factors, including financial need and the availability of resources. If you are currently receiving therapy but are seeking support through our initiative, you will be required to switch to a provider within our network to qualify for funding.

We are committed to maintaining confidentiality and handling your information with the utmost care and respect, in accordance with privacy laws.

Basic Contact Information

Full Name Email Phone Number Preferred Method of Contact

Eligibility

Are you 18 years of age or older? Are you currently receiving any form of mental health care or counseling? If you are currently receiving mental health care, would you be willing to switch to a provider supported by the Access to Therapy Initiative to qualify for funding? If you are currently receiving mental health care, would you be willing to switch to a provider supported by the Access to Therapy Initiative to qualify for funding? Do you have any form of health insurance or other resources that cover the cost of therapy? Based on your current financial situation, do you face challenges affording mental health care?

Consent and Confirmation

I confirm that I am over the age of 18

I understand that this application does not guarantee funding and that further verification may be required.

I agree to be contacted by the Access to Therapy Initiative regarding my application.

Data Privacy and Consent

I consent to my data being used for the purpose of processing this application and shared with practitioners and other relevant parties as necessary for the provision of therapy services.

I acknowledge that all personal information will be handled in accordance with privacy laws and will not be shared without my consent, except as required for the provision of therapy services.

I understand and agree that the Access to Therapy Initiative is not liable for any treatment provided by external practitioners.