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Copay Assistance · 501(c)(3) Nonprofit

Apply for Copay Assistance

Take the first step toward uninterrupted mental health care. Every application is reviewed with care, compassion, and full confidentiality.

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Who Can Apply

Am I Eligible?

This program is designed for insured individuals experiencing financial hardship that prevents consistent access to outpatient mental health care.

You May Qualify If You…

  • Have active health insurance with mental health benefits
  • Are responsible for copayments or coinsurance per session
  • Are experiencing financial hardship or limited income
  • Are receiving or actively seeking outpatient mental health care
  • Are working with a licensed therapist, counselor, or psychologist

What to Prepare

  • Proof of active health insurance
  • Estimated copayment or coinsurance amount per session
  • Basic financial need documentation or self-attestation
  • Name and contact information of your mental health provider
  • A brief description of your situation and financial need
How It Works

Simple. Confidential. Compassionate.

1

Submit Your Application

Complete the form below with your personal information, insurance details, provider information, and a brief description of your financial need.

2

Eligibility Review

Our team carefully reviews each application based on financial need, clinical necessity, and available program funding — typically within 5–7 business days.

3

Approval & Award Notification

Approved applicants receive a determination letter outlining their assistance amount and duration of support — with no hidden conditions.

4

Direct Payment to Your Provider

Funds are sent directly to your licensed provider — never distributed to clients — ensuring full transparency and compliance.

5

Ongoing Support & Monitoring

Our team stays available throughout your assistance period and can review renewals based on continued need and available funding.

Client Application

Mental Health Copay Assistance Application

All information is kept strictly confidential. Please complete every section accurately to help us process your application quickly.

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Personal Information

Name
Date of Birth

Insurance Information

Mental Health Provider Information

Financial Need

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Applications are reviewed within 5–7 business days. You'll be contacted by email. Questions? Call (561) 779-0748.

Need Help?

We're Here to Guide You

Our team is ready to assist you through every step of the application process. Your wellbeing is our priority.

(561) 779-0748 Contact Us

If you are having any suicidal ideation or mental health emergency, please call 911, go to your closest emergency room, or call the National Suicide Prevention Lifeline at 1-800-273-8255. This form is not designed for emergency services.

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