The Mind Card™ | Application for Therapy Support

The Mind Card offers limited therapy support based on available funding. Submitting an application does not guarantee approval. Prior participation does not guarantee additional support and may require further review.

Legal first name Legal last name Preferred name or nickname, if different Date of birth Age Gender identity (optional)

Is this applicant an adult or minor?

Adult Minor

If minor, name of parent or legal guardian Relationship of parent/guardian to applicant Best phone number for applicant or guardian Best email address for applicant or guardian Home address City State ZIP code

Has the applicant already chosen a therapist?

Yes No Not yet

If yes, therapist name Practice or clinic name Therapist email or office contact information, if known

Has the applicant already started seeing this therapist?

Yes No

If yes, approximately how many sessions have already occurred?

Is the therapist a current Mind Card partner?

Yes No Unsure

Is the applicant seeking:

What is leading you to seek therapy support at this time? What are you hoping therapy will help with right now? What makes paying for therapy difficult at this time?

Without support from The Mind Card, what would most likely happen?

Delay starting therapy Stop therapy Attend less often than needed Choose therapy over other essential expenses Other

Please share anything else you would like us to know about your situation (optional)

Has this applicant ever previously received support through The Mind Card?

Yes No Unsure

If yes or unsure, under what name was the applicant previously enrolled, if different? If yes or unsure, what phone number or email may have been used before? If yes, approximately when did the applicant last receive support?

Has this applicant ever completed all sessions from a previous Mind Card?

Yes No Unsure

Do you give The Mind Card permission to contact you about this application?

Yes No

Do you give The Mind Card permission to contact the listed therapist or practice only as needed to verify participation, coordinate support, or process claims?

Yes No

Preferred method of contact

Phone Email Text

Signature of applicant or guardian Date

The Mind Card

Applicant Information

Therapy and Provider Information

Need for Support

Prior Participation and Program Integrity

Understanding of the Program

Consent and Communication