COMPASSIONATE CARE FUND APPLICATION

Individuals, churches, and others have made donations to 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 “sliding scale fee” when clients are unable to pay the full cost of counseling. 

Please fill in the requested information and return it to our office as soon as possible.

CLIENT NAME________________________________________________  Date___________________

Income (total household)

_______$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 live 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 call the 800 number on the back of your insurance card and ask if you have any out of network benefits for mental health care.  If you have coverage, ask what specific benefits are provided.  Please list that information here:

__________________________________________________________________________________________

__________________________________________________________________________________________

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 do so.  If they are willing to help, please provide that information here:_____________________

Other Resources

A close friend or relative may be willing to help cover all or part of the cost of your visits.  Please list anyone who will be helping:

Name:___________________________________________ Phone:____________________

Address____________________________________________________________________

_______ Relative        _______ Friend

Name:___________________________________________ Phone:____________________

Address____________________________________________________________________

_______ Relative        _______ Friend

How much money are you able to invest for each counseling session?_____________

Signature: ____________________________________                        Date: _____________

Office Use Only:

AMOUNT TO BE GIVEN TO THIS CLIENT FROM THE COMPASSIONATE CARE FUND: