Grace Loncar Foundation Care Fund Portal

Facility Information

Name of facility, care provider, or practice *

Email *

Care Fund Eligibility Criteria

The client MUST pay a nominal portion of their treatment cost and meet ONE of the following eligibility criteria.

Client is between the ages of 12 and 26

Client is any age and has lost a loved one to suicide within the past 12 months

Explain the client's economic hardship: *

Describe other forms of funding client has explored: *

Will any services be provided pro-bono by the care provider?

Client Demographics

This information will only be used for program evaluation and statistical purposes. The Grace Loncar Foundation does not discriminate on the basis of race, color, religion (creed), gender, gender expression, sex, national origin (ancestry), disability, marital status, sexual orientation, citizenship, or military status.

Age:

Client's Residential Zip Code:

Gender:

Sexual Orientation: (optional but helpful)

Race and/or Ethnicity:

Name of Referring Provider:

Assigned Clinician:

Financial Responsibility

Client, alternative funding sources, and Grace Loncar Foundation (GLF) agree to pay the following amounts for requested service(s):

Counseling and Other Outpatient Treatments (EMDR, TMS, etc)

Number of sessions:

Cost per session: ($)

Client Responsibility ($)

Other funding sources ($)

Other funding details (insurance, Medicaid, etc):

Pro-bono services provided?

Pro-bono work value ($)

GLF Responsibility ($)

PHP/IOP Treatment

Number of weeks:

Cost per week: ($)

Client Responsibility ($)

Other funding sources ($)

Other funding details (insurance, Medicaid, etc):

Pro-bono services provided?

Pro-bono work value ($)

GLF Responsibility ($)

Psychological Evaluation

Cost for complete evaluation ($)

Client Responsibility ($)

Other funding sources ($)

Other funding details (insurance, Medicaid, etc):

Pro-bono services provided?

Pro-bono work value ($)

Write off expenses?

Write-off amount ($)

GLF Responsibility ($)

Residential Treatment

Cost for recommended program ($)

Client Responsibility ($)

Other funding sources ($)

Other funding details (insurance, Medicaid, etc):

Pro-bono services provided?

Pro-bono work value ($)

Write off expenses?

Write-off amount ($)

GLF Responsibility ($)

Client financial obligations will be remitted to the care provider or assignee. Grace Loncar Foundation does not collect and is not responsible for client payments.

7150 Skillman Street Suite 160 Box 129

Dallas, TX 75231

512-277-0485

carefund@graceloncarfoundation.org

Mental Healthcare Financial Aid Application and Approval Form

Facility Information

Care Fund Eligibility Criteria

Service(s) Requested

Client Demographics

Financial Responsibility

Counseling and Other Outpatient Treatments (EMDR, TMS, etc)

PHP/IOP Treatment

Psychological Evaluation

Residential Treatment