Mental Health Assistance Program Application

GiveMore Connections is able to offer a discount (up to 80%) on certain services based on a household’s income and insurance deductible size through the Mental Health Assistance Program (MHAP). Calculations are determined by using an applicant’s total household annual income and are based on the most recent Federal Poverty Guidelines.

If you wish to qualify for the MHAP, you must show proof of income for all family members/individuals living in your household or individuals for whom you are financially responsible. In addition, you will need to provide proof of insurance deductible that must surpass a minimum of $1500 Individual/$3000 Family. Applicants who apply must be approved by the GiveMore Connections Board or Founders.

You will be asked to upload the following items with your application:

Previous year’s Federal Tax Return, W-2’s or 1099’s (Income will come from total income line)
Most recent pay stubs spanning four weeks
Social Security or Pension Income
Proof of Insurance Plan and Deductible Amount

Your MHAP discount will be assessed once per year. You must reapply for the MHAP discount and provide updated income documentation and be approved by the GMC Board or Founders.

PLEASE NOTE: You may be responsible for the payment of some procedures, labs, and medications. If you have any questions, please contact GiveMore Connections directly at givemoreconnections@gmail.com

Name

First Name

Last Name

Email Address

Date of birth

MM

DD

YYYY

Phone number

(###)

###

####

Do you have a preference for faith-based counseling?

Do have insurance?

Yes

No

Disclaimer:

I hereby certify that the above information is, to the best of my knowledge, true and correct. I further agree to notify GiveMore Connections any changes in this information within ten (10) days of such change. I understand that I must re-qualify annually to maintain my eligibility. I am also aware that this information is reviewed and based upon Federal Poverty Guidelines, published annually by the Federal Government. MHAP payment is due and payable at the time of service. To maintain discount, fees must be paid promptly. If you are unable to make payment at time of service, please contact the GiveMore Connections to make other payment arrangements.

Yes, I agree.