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 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___________________

Phone #______________________________  Email_________________________________________________________________________

Income (total household) Please provide proof of income, i.e. paystub

_______$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, they will tell you what those benefits are.  Please call the office manager 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 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 person to be billed:

Name:___________________________________________ Phone:____________________

Address___________________________________________________________________ 

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

 Signature: _________________________________________________                        Date: _____________

After review of this application, we will contact you.  Your adjusted fee will be for 5 sessions after which another review will take place.

Office Use Only:

                                                                                                                                                                               Approved fee amount $__________