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Application for Financial Assistance
Welcome to Heartspace Kids! We are a 501c3 non-profit organization dedicated to providing access to essential mental health care and critical educational resources by removing financial barriers for those in need. Thank you for taking a few minutes to fill out this form. The information you provide is confidential. Heartspace Kids will contact you by phone within 14 days of your application submission.
**This financial assistance is for kids ages 18 and younger or up to 21 years of age when receiving special education services.**
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* Indicates required question
Email
*
Your email
Is your child in crisis now?
The Colorado Crisis Services hotline has counselors available to talk 24 hours a day, seven days a week at 1-844-493-TALK (8255) or text TALK to 38255. Or visit the Colorado Crisis Services website to learn more about how to speak with a counselor.
https://coloradocrisisservices.org/
Level of Need for Care
It can take up to 14 days to process your application for financial assistance. Please tell us your child's level of need for care.
Level of Need for Care
Not Urgent
1
2
3
4
5
Extremely Urgent
Clear selection
Date
*
MM
/
DD
/
YYYY
Your Name
*
Your answer
Your Date of Birth
*
MM
/
DD
/
YYYY
Complete Address (include city, state, and zip)
*
Your answer
Phone
*
Your answer
Is this a mobile phone number?
Yes
No
Clear selection
Referred by:
*
Your answer
Service(s) Applying For:
*
Individual Therapy for Child/Teen
Family Therapy
Group Therapy for Child/Teen
Educational Therapy for Child/Teen
Educational Group for Child/Teen
Parent Workshop
Other:
Required
Who will be using this service?
Please include name, date of birth, and relationship to you.
1-Name, DOB, Relationship to you
*
Your answer
2-Name, DOB, Relationship to you
Your answer
3-Name, DOB, Relationship to you
Your answer
4-Name, DOB, Relationship to you
Your answer
Primary Language Spoken in the Home
*
Your answer
Are you curently experiencing homelessness?
Yes
No
Clear selection
In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?
Food
Clothing
Utilities
Child care
Medicine or other healthcare
No
I choose not to answer
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Yes, it has kept me from medical appointments
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
I choose not to answer
Number of Members in Household Including Yourself
*
Your answer
Are you a one-parent household?
Yes
No
Clear selection
Total Annual Household Income (include all income: child support, spousal support, disability, etc.)
*
Your answer
Please describe any other financial information or extenuating circumstances you'd like for us to consider when reviewing your application.
Your answer
Do you have health insurance that includes mental health coverage?
*
Yes
No
If yes, who is your insurance carrier? (If no, please type N/A.)
*
Your answer
If yes, why aren't you using your insurance?
*
N/A
Co-pay is too high
Deductible is too high
Coverage limits the number of appointments
I can't find a provider who takes my insurance
I don't want to go through my insurance because of privacy concerns
Other
Required
Please add any additional information you'd like for us to know?
Your answer
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