Information provided in this application is 100% confidential and is managed securely.

Applicant
The term “applicant” refers either to the parent or guardian applying for financial assistance for therapy for their teenager(s), or to a young adult applying for financial assistance for therapy for themselves.

Financial assistance recipient
The term “financial assistance recipient” refers to either the teenager or young adult who would receive financial assistance from Emotional Relief Fund if approved.

Each applicant will need to provide verification of household income by submitting a digital photo or a scan of one of these documents for each person in the household who earns income:

• Most recent prior year W-2 statement
• Most recent prior year tax return
• Most recent pay stub
• Letter from employer stating current job income

Eligible applicants must prove household income that is currently at or below 400% of the Federal Poverty Level (FPL) for the number of persons in their household. See this updated FPL table for reference.

Eligible financial assistance recipients must be 12 years old or older, and younger than 26, on the date of application.

The medical diagnosis of the applicant / financial assistance recipient will be left solely to the treating therapist. Emotional Relief Fund will make decisions on financial assistance based solely on the financial need displayed by the applicant.

If approved, the financial assistance recipient will have 12 months from the date of approval to use the approved funding. If the funds are not used and there is still a need, the recipient can reapply after these 12 months end.

If approved, Emotional Relief Fund will provide up to $2,500 per financial assistance recipient per lifetime. This money will be available solely through payment to the recipient’s therapist for
visits already performed and billed by that therapist or therapy practice. Only visits performed
after the date of Emotional Relief Fund approval are eligible for financial assistance. Applicants
will be responsible for arranging payment for any visits or dates of service performed prior to
Emotional Relief Fund’s written approval.
Payment will be made directly to the treating therapist(s) within 45 days after the date Emotional
Relief Fund is billed by the therapist.

We want to provide funding for as many individuals as possible and ensure that those receiving funding are committed to treatment. Therefore, if a recipient misses two sessions with less than 48 hours’ notice provided to the therapist (i.e. is a “no show” or late cancel), funding will be terminated and no additional funding will be available.

By completing this form, you are attesting that the answers provided are true to the best of your knowledge. Any false statements or information will result in the immediate disqualification from the Emotional Relief Fund financial assistance review process and/or receipt of funding from Emotional Relief Fund, even if some funds have already been paid to a therapist.