Honeybee Helps Financial Form

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Honeybee strongly believes that all children should have access to the therapy they need without adding financial stress on the family. If you need assistance meeting the financial aspect of services at Honeybee, please fill out this form to learn about the options available to you.

Child's Name *

Parent/Guardian's Name *

Phone # if we have questions *

Are you having difficulty paying for your child's therapy? *

Yes

Other:

What are you having difficulty paying? *

Deductible

Co-payments

Co-insurance

Treatment Fee; No Insurance

Treatment Fee; Benefits have maxed out for the year

Treatment Fee; Therapy is not a covered service

Other:

Required

There are some foundations, grants and scholarships available to help families that are uninsured, under insured, maxed out benefits, high copays/deductibles. Are you willing to apply to alternate funding sources to meet your financial obligation? *

Yes

Unsure

Other:

How much could you reasonably pay for each treatment session? (If your child receives multiple sessions, please feel free to indicate a weekly or monthly amount if that is easier) *

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