The Mind Card™

Application for Therapy Support

Thank you for your interest in The Mind Card™.

The Mind Card™ helps reduce financial barriers to mental health care by providing limited therapy support based on available funding.

Applications are reviewed individually according to program guidelines, provider participation, and available funding. We review applications on the 5th of each month.

Please complete this application as accurately as possible so we can better understand your situation and how support may help. Submission of an application does not guarantee approval.

The Mind Card is not a crisis service. If you are in immediate danger or experiencing a mental health emergency, call 911 or 988.
1

Applicant Information

Tell us a little about yourself and how we can best reach you regarding your application.

Is this applicant an adult or minor?

How did you hear about The Mind Card?

Preferred method of contact

2

Therapy and Provider Information

Tell us whether a therapist has already been chosen and what the expected therapy costs look like.

Has the applicant already chosen a therapist?

Has the applicant already started seeing this therapist?

Is the therapist a current Mind Card partner?

3

Financial Barriers, Access, and Impact

Help us understand the financial barrier, the emotional impact, and what assistance would change for you.

What is preventing you from accessing therapy right now?

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

What is your primary reason for seeking therapy?

Have financial concerns caused you to delay or avoid therapy in the past?

4

Grant Questions

These questions help The Mind Card tell the broader affordability story to donors and grant funders. They do not determine eligibility.

Are there children under age 18 living in your household?

Do you provide regular care for another person?

Is this your first time seeking therapy?

Do any of the following apply to you? (Select all that apply)

5

Prior Participation and Program Integrity

These questions help us avoid duplicate support and better understand previous participation.

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

6

Final Confirmations Before Submission

Please review the information below and confirm the key acknowledgments before submitting the application.

The Mind Card only covers up to $50 per session, for 6 sessions, but not more than out of pocket expense.

The Mind Card does not cover payment for past sessions or services provided prior to approval.

The Mind Card may use de-identified and aggregated application data for program evaluation, fundraising, grant reporting, and impact measurement.

The Mind Card may contact the listed therapist or practice as needed to verify session rate, out-of-pocket cost, provider participation, and process claims.

False, incomplete, duplicate, or misleading information may result in denial, cancellation of support, or removal from the program.

By submitting this application, you agree to the above terms and authorize The Mind Card to review and process this application for the purpose of determining program eligibility and administering assistance.