FINANCIAL ASSISTANCE FORM

Connections without Barriers offers quality, low-cost, and free therapy for individuals of all ages, ensuring everyone has access to essential mental health care.
Full Name
Preferred Contact Method
Type of Services Requested
Support requested for
Do you have a preferred CWBF approved provider?
If yes, please enter name below
Are you Currently Receiving therapy or neurofeedback?
If yes, list provider
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Monthly Household Expenses (Expense Type/ Monthly Amount)
Attach additional pages if needed.
Document Checklist (At Least one required)
Optional
Upload your file
Consent & Acknowledgments
By submitting this document the client agrees to the following
Accessible Mental Health Services
Please provide accurate information about your current household and financial situation. This information is used solely to determine eligibility for reduced-fee or scholarship services through our nonprofit program.  We understand that financial circumstances can be complex, especially for military families and individuals experiencing transition, unemployment, or other hardships.
Financial Assistance Form