How to apply for fund assistance -
This application requires basic demographic information from you for documentation purposes. It goes directly to Michele G. Stanton, LCSW-C, who is the only person on the Board who will see your name and information. The Board understands the importance of maintaining your privacy and your information is protected by HIPAA. You can be assured that your personal information will not be shared.
As the fund is designed to disburse financial support directly to the provider who will be treating you, we ask that you enter your provider's name and contact information on the form. Your case will be presented anonymously to the Board of Directors for approval of funds. Once approved, Ms. Stanton will send out a letter with directions to you and your provider about how to submit statements for payment. Funds then are disbursed to that provider directly as we receive their billing statements for your sessions/treatments.
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.
If you currently do not have a therapist/counselor, please contact us and we will attempt to find someone for you. Again, your privacy is of utmost importance to us.
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 a Word Doc email for you to complete and return via surface mail address.