Patient Assistance Fund Application - Change Your Brain Foundation

Patient Assistance Fund
Nemec Abbott Foundation

Please fill out the application below to apply.

First Name

Last Name

Title

Phone

Mailing Address

Date of Birth

Referred by (specify name and relationship):

Are you applying for yourself?
YesNo

(If not, please state your name and relationship to the applicant):

Why are you seeking care at Amen Clinics?

How have these concerns impacted your daily life?

Have you been diagnosed with any psychiatric or neurological disorders?

What types of help/interventions have you already sought and what were the outcomes?

Rate your current percentage of normal functioning, 100% being expected normal, for the following areas (scale 0-100%):

Cognitive:

Physical:

Emotional:

What are your primary goals and expectations for treatment?

Why do you need financial assistance to access Amen Clinics’ services?

Is there anything else we should know about you?

What specific help are you asking the Foundation to provide?

Eligibility Verification: Please upload your driver’s license. Patients must verify that they are a resident of the PD Region of South Carolina, which includes Chesterfield, Darlington, Dillon, Marrion, Florence, or Marlboro Counties.

Do you Consent to Providing a Video Testimonial
YesNo

Do you Consent to receive Follow Up Feedback via Text, Phone Calls, and Email
YesNo

Patient Assistance Fund Nemec Abbott Foundation

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Patient Assistance Fund
Nemec Abbott Foundation