• We are glad you are here!

    We are glad you are here!

    This is the start of the application process for NEW and RETURNING applicants.
  • What type of application are you going to be filling out today?*
  • Do you know your application number?
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  • Enter your application number and then click "Submit Application Number" to access your previous application details
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  • Applicant Details

    Sponsorships are awarded to the individual indicated in this section only. Sponsorships cannot be shared or transferred. This section is about the individual that will be participating in therapy. **If applying for couples counseling then please fill this form out with the main client contact/billing information.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today (hidden form calculation)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Gender*
  • Ethnicity*
  • What is your relationship Status?*
  • 0/50000

  • MINOR - Parent/Guardian information

    The information provided indicated that you are applying on behalf of a minor and therefore we require information about the parents/guardians of the applicant.

  • MINOR - Parent/Guardian #1

    Please fill in the details below regarding the parent/guardian filling out this application. Anytime you see "P1" next to a question, please know that is referring to the parent/guardian you have listed in this section.
  • P1- How would you best describe the living arrangements between the applicant and the parent/guardians?
  • P1- What is your relationship to the child?
  • P1- Does the applicant reside with this parent/guardian at least 50% of the time?
  • P1- Gender
  • Format: (000) 000-0000.
  • P1- What is your relationship Status?

  • You indicated that the child does not have contact with their other parent/guardian, but that they do not live with you at least 50% of the time.

    Please fill in the "Parent 2" section with details for the guardian that the child resides with more than 50% of the time. 

  • MINOR - Parent/Guardian #2

    Please fill in the details below regarding the other parent/guardian of the child. Anytime you see "P2" next to a question, please know that is referring to the parent/guardian you have listed in this section.
  • P2 - What is the relationship to the child?
  • P2 - Gender
  • Format: (000) 000-0000.
  • P2 - What is your relationship Status?

  • Therapy & Your counselor

    This section will cover the details about your preferred provider. All information in this section is required. If you type in "none" or leave sections blank you will automatically be denied.
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  • Are you seeking counseling voluntarily or are services being ordered by a court of law?*
  • Do you currently have a therapist?*
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  • Have you already completed your first, 'intake', session with your therapist?
  • What Specialties does your counselor have that you are seeking? (select all that apply)
  • PROVIDER LOOKUP
  • Format: (000) 000-0000.
  • How did you find your therapist?

  • Please provide details below about the type of therapy that you are hoping to receive financial assistance for.

    The HOPE Foundation is able to financially assist with one type of therapy with one provider per applicant. We understand that some applicants are in multiple groups/programs as well as individual/couples/family therapies. Unfortunately, in order to help as many people as possible we can only financially assist with one. Please determine which mode would be the most important for you to have assistance with. The HOPE Foundation encourages you to participate in all therapy’s that you and your therapist find valuable, and this is in NO WAY a treatment plan. You can participate in all types of therapy, but HOPE can only financially help with one.
  • What type of therapy are you needing financial assistance with?

  • Individual Therapy

  • Couples Therapy

  • Family Therapy

  • EMDR Therapy

  • Neurofeedback Therapy

  • How many sessions have you already had with your counselor?

  • Group Therapy

    With an end & start date

  • Group Therapy

    A continuous program
  • How long have you been attending this group?
  • Do you have an estimate of how long you will be participating in this group? (if you are already attending this group, please select how much longer you anticipate you will be in this group)

  • Mental Health History

    and treatment
  • Have you ever been diagnosed with a specific mental illness?
  • What is your diagnosed mental illness?
  • Have you ever been treated for mental illness in the past?

  • Education

  • MINOR - What grade in school is the applicant?
  • What is the highest level of education have you obtained?
  • Are you a full-time or part-time student?
  • What trade school certificates do you have? (Check all that apply)

  • Minor - Parent/Guardian #1

    Education
  • P1 - What is the highest level of education have you obtained?
  • P1 - Are you a full-time or part-time student?
  • P1 - What trade school certificates do you have? (Check all that apply)

  • Minor - Parent/Guardian #2 Education

  • P2 - What is the highest level of education obtained?
  • P2 - Are you a full-time or part-time student?
  • P2 - What trade school certificates do you have? (Check all that apply)

  • MILITARY & FIRST RESPONDERS

    Sometimes donors give funds specifically for our military and first responders. We need to know if you could qualify for these funds.

  • Military

  • Are you currently, or have you ever been, in the United States Military?
  • What is your current status with the United States Military?
  • What Branch of the Military?
  • Are you a direct family member of a current, or former member of the United States Military?
  • What is your relationship to your relative in the military?
  • What is your family member's current status with the United States Military?
  • What Branch of the Military was/is your family member in?

  • First Responder

    FIRST RESPONDERS are those with specialized training who is among the FIRST TO ARRIVE & PROVIDE ASSISTANCE in an EMERGENCY. They are EMT, Paramedic, Firefighter, Police officer, and [sometimes] EMERGENCY ROOM doctors & nurses.
  • Are you currently, or have you ever been, a First Responder?
  • What is your current status as a First Responder?
  • What is/was the line of duty for you, as a First Responder?
  • Are you a direct family member of a current or former First Responder?
  • What is your relationship to your relative that is a First Responder?
  • What is your family member's current status as a First Responder?
  • What is/was the line of duty for your First Responder?

  • Employment:

  • Select the option that best applies to your (applicant) employment status:
  • How long have you been out of work?
  • Are you seeking employment?

  • Minor - Parent/Guardian #1

    Employment
  • P1 - Select the option that best applies to you:
  • P1 - How long have you been out of work?
  • P1 - Are you seeking employment?

  • Minor - Parent/Guardian #2

    Employment
  • P2 - Select the option that best applies to Parent/Guardian#2:
  • P2 - How long has parent 2 been out of work?
  • P2 - Are they seeking employment?

  • Medical & Mental Health Benefits

    Please read the infographic below to understand why we ask for this
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  • Why does HOPE want to know about your mental health insurance?

  • Even if you have insurance, we can still help you pay for your therapy! We have helped applicants when their deductible is too high or when they have a copay that they just can’t meet! We are here to help everyone with a financial need!

    Please select a different answer to continue.

  • The HOPE Foundation believes that not every therapist is right for every person! We KNOW the importance of finding a therapist that is going to help you meet your goals. Sometimes that therapist is not covered by your plan. We understand that!

    Please select a different answer to continue.

  • We really don't mean to be nosy... but our donors need to know the real reasons why this foundation is so vital to everyday people! 

    Please select a different answer to continue.

  • Do you have Health Insurance? (select all that apply)*
  • Is your insurance through the VA or TRICARE?
  • Do you have mental health benefits through your medical plan? (Even if you are not going through your insurance, please answer honestly.)
  • Do you have a deductible for your mental health benefits? (Even if you are not going through your insurance, please answer to the best of your ability)
  • What month does your insurance benefit year begin? (When does your deductible start over?)
  • Have you looked for a therapist that takes your insurance?

  • Financials

  • Please check your answers.

    The total number in your household should equal the number of adults plus the number of children. 

  • HOUSEHOLD INCOME

    Please include all contributing income. Such as: Employment, Disability, Spousal Support, Child Support etc.
  • Are you, or other contributing adults in your household, currently employed as a W-2 employee?*
  • Are you, or other contributing adults in your household, currently self-employed or a '1099' contractor?*
  • Do you, or other contributing adults in your household, have Social Security Income?*
  • Do you, or other contributing adults in your household, have unemployment Income?*
  • Do you, or other contributing adults in your household, have retirement Income?*
  • Do you, or other contributing adults in your household, have rental property Income?*
  • Do you, or other contributing adults in your household, have any other type of Income?*

  • Household Expenses

    Please fill out this worksheet to the best of your ability. We understand that sometimes expenses can change seasonally. In those categories, please use a monthly average (Cost for 12 consecutive months divided by 12)
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  • COST OF LIVING

    COST OF LIVING

    Please tell us what your MONTHLY cost is for each of the categories below
  • MISC HOUSEHOLD

    MISC HOUSEHOLD

    Please tell us what your MONTHLY cost is for each of the categories below
  • TRANSPORTATION

    TRANSPORTATION

    Please tell us what your MONTHLY cost is for each of the categories below
  • EDUCATION

    EDUCATION

    Please tell us what your MONTHLY cost is for each of the categories below
  • MEDICAL

    MEDICAL

    Please tell us what your MONTHLY cost is for each of the categories below
  • FAMILY

    FAMILY

    Please tell us what your MONTHLY cost is for each of the categories below
  • SAVINGS & INVESTMENTS

    SAVINGS & INVESTMENTS

    Please tell us what your MONTHLY cost is for each of the categories below
  • DEBT

    DEBT

    Please tell us what your MONTHLY cost is for each of the categories below
  • MISCELLANEOUS

    MISCELLANEOUS

    Please tell us what your MONTHLY cost is for each of the categories below

  • Financial Overview

    According to your responses this is what your financial position looks like. If this is incorrect please go back and make edits where necessary.
  • Are you receiving any financial assistance from family or friends?*
  • Are you receiving any financial assistance from your church or a religious institution?*
  • Are you receiving any financial assistance from the state or federal government?*
  • Are you receiving any financial assistance from any other source or program?*

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  • Is the income on your tax return the same as this year?
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  • ACKNOWLEDGEMENT*
  • Should be Empty: