REQUEST FOR FINANCIAL ASSISTANCE

Thank you for applying for therapy cost assistance through The Mental Health Society! Please review the following information carefully before proceeding with your application.

EMERGENCY NOTICE

If you or someone you know is experiencing a mental health crisis, please call 911 or go to the nearest emergency room immediately.

ELIGIBILITY

This program is available to Houston students who need financial support for therapy outside of school. The Mental Health Society provides funding for up to 12 sessions, which can be used at your own pace.

SESSION ATTENDANCE POLICY

If you or your child miss a session without providing at least 48 hours' notice to the therapist, The Mental Health Society will not cover the cost of that session. You will be responsible for the full fee in cases of no-show or late cancellation.

CONFIDENTIALITY

Your privacy is a priority. All information shared during therapy remains confidential unless there is a risk of harm to yourself or others, or you provide permission to share information.

I acknowledge the information above and agree to cover the full cost of any session if I fail to attend or cancel without sufficient notice.

Student First and Last Name

Grade Level & Campus

Student Cell Phone Number

If you are under 18, please provide your parent’s name and phone number.

Please describe your circumstances that create the need for financial assistance with counseling. For example, explain your financial situation and whether your parents or guardians support your decision to seek therapy and assistance. All information is confidential.

How soon would you like to begin counseling?

Are you and/or your parents willing to sign a Release of Information with Pinkerton Psychotherapy, allowing us to handle payments on your behalf? Note: This release is solely for payment purposes, and no other information will be discussed with your therapist.

Thanks for your submission! Our partner practice will contact you soon to schedule your first appointment.