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Financial Assistance Application

He/Him; She/Her; They/Them; Etc...

Birthday
Month
Day
Year
Preferred Method of Contact:
Have you previously received therapy or counseling services?
Yes
No
Are you currently receiving therapy or counseling services?
Yes
No
If you are currently receiving therapy or counseling services, would you like to continue with your current therapist?
Yes
No
Do you prefer virtual (online) or in-person therapy?
Virtual
In-Person
No Preference
What is your current financial situation?
Employed Full-Time
Employed Part-Time
Unemployed
Student
Other
Do you have health insurance that covers mental health services?
Yes
No
If yes, does your insurance fully or partially cover therapy sessions?
Fully Covered
Partially Covered
Not Covered
Are financial barriers preventing you from accessing therapy right now?
Yes
No

$________ per session

Would you like to choose a therapist from Arielle's Light network?
Yes
No, I already have a therapist I'd like to continue with

Therapist Name, Email, Phone #, License # (if readily available)

How did you hear about Arielle's Light?

  • I confirm that the information provided is accurate and truthful to the best of my knowledge

  • I agree to follow the outlined process for accessing therapy through Arielle's Light

  • I consent to communication from Arielle's Light via my preferred contact method.

  • I understand that all information provided will remain confidential

  • I understand that Arielle's Light will have not have access to therapy session details, as confidentiality is protected between the therapist and client.

  • I understand that Arielle’s Light will initially cover the cost of up to 4 individual therapy sessions.

  • I understand that any additional sessions may be covered with approval, but not guaranteed.  

  • Our responsibility is limited to financial assistance and facilitating connections between clients and therapists within our network.

  • The therapist-client relationship is independent of Arielle’s Light. Any issues, concerns, or disputes regarding therapy services, treatment approaches, or outcomes must be addressed directly with the therapist.

  • Arielle’s Light does not guarantee the effectiveness of therapy, the resolution of mental health struggles, or any specific results from sessions funded through our program.

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