• CLIENT ASSISTANCE PROGRAM ELIGIBILITY FORM

    Eligibility for this program is based on financial need.
  • Proof of income is required to qualify for the Client Assistance Program (CAP). Along with this application, you will need to submit a statement of earned income, which may be obtained from the Federal Building on 12th Street. As an alternative, you may submit your most recent income tax return or your two most recent pay stubs. The information must be updated every six months and anytime your income, household size, and/or medical insurance status changes. Whether or not a discount has been applied to your fee(s), you are responsible for the full payment of your bill.

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    Pick a Date
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  • If yes, please provide the following insurance information:

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  • Category of Earnings

    List all earnings and benefits that you are receiving in your household
  • Please list two references who are not living with you:

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  • I authorize Continuing Hope Counseling LLC to verify information provided on this application. I also authorize all government agencies, employers, financial institutions and any companies, agencies or persons listed herein to provide information about me to Continuing Hope Counseling LLC. I understand that false statements made on this application are punishable. I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge. I further understand if any information is found inaccurate, I may be denied a discount and/or subject to criminal prosecution for knowingly providing false information. I agree to notify Continuing Hope Counseling LLC of all changes in income, address, living arrangements, number of household members and/or other circumstances. I understand that the information given above will be kept confidential, except for the purposes noted above, and not released without my written permission. I also understand that if I do not agree with any decision made concerning this application, I have the right for a review in writing.

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