Client Assistance Fund Application
(Please read carefully and thoughtfully)
Client(s) Name:_______________________________________________________________
Care and Counseling is a private, non-profit organization that was established in 1968. Our mission is to enhance
emotional, relational and spiritual well-being through quality and affordable counseling, professional training and
community education.
We welcome each and every client to our facilities located throughout the St. Louis metro area. We strive to make your
visits with us as comfortable and inviting as possible. We have over 20 professionally trained counselors and 4
psychiatrists available to assist children, adults, couples and families from the age of 3 to 93 and everywhere in
between. We invite you to feel welcome and a part of our mission of providing anyone who walks through our doors
with a little more hope and healing in their lives. If we can ever assist you in any way, please feel free to talk with your
counselor or any of our office staff.
What is the Client Assistance Fund (CAF)?
At Care and Counseling, part of our mission is to provide counseling to people who do not have health insurance
coverage and might have difficulty affording our services. Financial need can impact any individual or family.
Accordingly, the Care and Counseling Client Assistance Fund is available to subsidize a portion of your fee if you are
unable to pay the standard fee. Everyone is required to pay a fee for counseling services, but the CAF reduces the
portion you are required to pay.
Who provides CAF Funds?
Each year the Care and Counseling Board of Directors raises funds to support our CAF through a variety of fundraising
activities in which congregations, corporations, foundations and individuals in our community offer contributions in
support of our mission. We do not receive funds from United Way, nor do we receive support from any government
program.
How is my portion of the fee established?
Your fee is established based on a combination of household income, resources and expenses. Once you have filled out
the CAF Application and have provided proof of income, you will discuss your application and any related financial issues
with your counselor who will use a sliding scale to establish the fee - most often in your first session.
What should I consider before applying for CAF Funds?
The CAF Funds are provided for those who are unable to pay the standard fee. Before applying for CAF Funds, we ask
you to consider the following:
 Do I have a savings account, investments or other assets?
 Do I have a family member who can provide financial support to aid in my therapy?
 Do I have an employer or congregation that would be willing to contribute to my therapy?
 Am I married, but cannot use the income of my partner because I would be physically endangered if
they discovered my therapy?
Page 1
Client Assistance Fund Application
Date of Application:
_____/_____/__________
Name of client: _____________________________________________________________
Name of responsible party: ___________________________________________________
List other types of Income (unemployment compensation, any and all government aid, social security, worker’s
compensation, pension, rental income, alimony, child support, interest income, cash gifts etc).
Source of Income
Amount
Source of Income
Amount
1_____________________________________________
4____________________________________________
2_____________________________________________
5____________________________________________
3_____________________________________________
6____________________________________________
List other Assets or Accounts (checking accounts, savings accounts, investments) and Amounts:
1____________________________________________
3___________________________________________
2____________________________________________
4___________________________________________
Other Third Party(ies) who will be paying a portion of the fee (family, employers, church):
TOTAL HOUSEHOLD INCOME PER YEAR (GROSS): $_______________________
**NOTE: It is the policy of the Care and Counseling Inc that individuals applying for any Client Assistance Funds provide
verification of income, such as tax return and/or pay stub, or similar proof. Please bring copies of these documents with
you, to your first appointment.
 I have read the information on page 1 regarding Client Assistance Funds and confirm that I do not have other
means to pay for my fees. __________ (Please initial here).
 I understand that my financial status will be reviewed on a regular basis and that my fee may be adjusted
when/if my financial circumstances change.
 I understand that a change in my insurance status should be reported immediately, to my counselor.
 I understand that I will be billed my agreed upon session fee for any missed or cancelled (with less than 48
hours notice) sessions.
Client or Parent/Legal Guardian Signature
Date
Counselor Signature
Date
FOR CARE AND COUNSELING USE:
Of the $150 First/$135 Ongoing Session Fee:
Client is to pay this amount:
Third Party will pay this amount:
Amount of assistance funds used:
Name and contact information for third party:
Approved By:
Page 2
If you would like to apply for additional assistance based on income and expenses, please fill
out page 2 of this application.
List members of the Household
Relationship
Birth date
Occupation
Salary
1_________________________________________________________________________________________________
2_________________________________________________________________________________________________
3_________________________________________________________________________________________________
4_________________________________________________________________________________________________
5_________________________________________________________________________________________________
List monthly expenditures:
Mortgage/Rent
$________________
Telephone(s)
$ ________________
Food
$________________
Auto(s)
$________________
Auto Insurance
$________________
Medical Insurance
$________________
Medications/Dr’s
$________________
List other outstanding debts:
Name of Company
1
2
3
4
5
6
Please explain any significant financial factors:
Property Taxes
Electric/Gas/Water
Cable/Internet
Other Utilities
Other Auto Exp
Clothing
Other_____________
Balance Owed
$________________
$________________
$________________
$________________
$________________
$________________
$________________
Monthly Payment