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Synergy eTherapy Health-E Counseling Fund for Minnesota clients - Application
We are so glad you are here!! Please complete this form to apply for financial support to help offset some of the costs for online therapy with one of our incredible Synergy eTherapists!
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Today's Date
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Name (First and Last)
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Your answer
Your Email Address
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Your answer
Address (including State you live in)
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Your answer
Your Phone Number
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Your answer
Age of desired client to receive these funds
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Your answer
Gender of desired client to receive these funds
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Your answer
Race/Cultural Background
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Your answer
Who will be using the funds for eTherapy?
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Choose
Me (OVER 18 yrs old)
Family member (UNDER 18 yrs old)
Family member (OVER 18 yrs old)
Myself and my family/partner for Family/Couples Therapy
Please tell us a little about why you could use financial support from our Health-E fund for online therapy with Synergy eTherapy!
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Your answer
It would help me greatly to receive support for eTherapy services at the following total dollar amount:
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$25
$50
$100
Other:
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When do you need to begin therapy with a Synergy eTherapist?
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ASAP
Within 2 weeks
Within the month
Other:
Money given from this fund will only help offset the cost of your Synergy eTherapy sessions. Most engage in therapy anywhere from 3-18 sessions on average. (please check ALL boxes below that you understand the terms and conditions).
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I understand that money from the fund will be deducted from my eTherapy sessions and I do not personally receive money from the fund.
I understand that after I use the money for my session from the fund, that I will be responsible for the remainder of my eTherapy sessions.
If using insurance, I understand that money from the fund will be used towards my deductible, copay or coinsurance.
I understand that even though I may receive funds to help towards eTherapy, it will only be deducted after a session (or after as many sessions as needed until the funds run down).
I understand that these funds are only given to be used for therapy with a therapist who works within Synergy eTherapy.
I understand that filling out this application does NOT guarantee that I will be awarded financial aid to help offset the costs of eTherapy.
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By checking this box, it is as good as an electronic signature. We will reach out to you with further instructions shortly. If you have additional questions, please email Info@SynergyEtherapy.com.
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I agree that this form was completed honestly and thoroughly. By checking this box, I agree to the terms and conditions.
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