AHM Reduced Fee Therapy Application

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Adventures of the Heart & Mind (AHM) is committed to serving those in need of mental health services, regardless of ability to pay. AHM provides several options to reduce the financial concerns of clients while balancing the needs of our organization and staff to provide the highest level of quality service.

Though we cannot guarantee the availability of these options at all times, we will always do our best to try and work with each person’s unique situation. If there are no reduced fee slots available, we are more than happy to place you on a waiting list and inform you when a slot becomes available.

AHM utilizes a standardized income based sliding scale which takes family size into consideration. AHM does not require income verification, as we would like to eliminate systemic barriers such as lengthy verification processes to get those in need services faster. We trust that you, the client, will honor this agreement and provide accurate and up to date information.

Once you complete this application, and AHM team member will reach out to let you know what options we currently have available for you.

Email *

First Name *

Last Name *

What is a good contact phone number for you? *

Are you currently experiencing financial hardship? Please briefly describe your need for financial assistance. *

What is your annual household income (after taxes)? *

Are you open to teletherapy (due to COVID-19 restrictions)? *

Yes

Would you like to subscribe to our email list for future offers, options, events, and mental health resources? *

Yes

By completing this application, I am confirming that the above information is complete and correct. I understand that this application is not a guarantee of services. I understand providing false or inaccurate information may result in disqualification from this program. *

I agree and confirm the above information provided is correct.

Required

A copy of your responses will be emailed to the address you provided.

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