To financially assist you with supportive treatment we ask that you provide the name and contact information for the provider who will be treating you. Once your funds have been approved by our Board of Directors, you and your provider will receive a letter with directions about how to submit those statements. Funds are disbursed to that provider as we receive the provider’s billing statements for your sessions.
The adjacent application also requires basic demographic information from you for documentation purposes. The Board understands the importance of maintaining your privacy. Your information is protected by HIPAA. You can be assured that your personal information will not be shared. Clinical oversight is provided by medical professionals who are licensed to provide such oversight and monitoring.
If, at any time in the process, you decide not to receive these funds, please notify us in writing. At that time. the “Release of Information” from your provider will be cancelled. Your application process for continuing funds will then be discontinued.
We appreciate your trust in us. We are honored to support you in this healing journey, Please direct any questions or concerns to:
Michele G. Stanton, LCSW-C
To receive consideration, please complete the form below or ask for this request form using the contact box on the home page. You will be sent an Word Doc email for you may complete surface mail address: