Patient Assistance Fund Application - Change Your Brain Foundation

Patient Assistance Fund
Nemec Abbott Foundation

Please fill out the application below to apply.

* Applicants age 18 or older must complete their own application, unless they require assistance due to a disability or other circumstance that prevents them from doing so independently.

This field is for validation purposes and should be left unchanged.

Are you applying for yourself?(Required)

Yes

Submitter Information

Submitter First Name(Required)

Submitter Last Name(Required)

Relationship to Patient(Required)

Submitter Email(Required)

Submitter Phone(Required)

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Patient Date of Birth(Required)

Title(Required)

Patient Email(Required)

Patient Phone(Required)

Patient Address(Required)

House Number & Street City State / Province / Region ZIP / Postal Code Country

Referred by (specify name and relationship)(Required)

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(Required)

Please enter a number from 0 to 100.

Physical(Required)

Please enter a number from 0 to 100.

Emotional(Required)

Please enter a number from 0 to 100.

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(Required)

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.

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 10 MB.

Do you Consent to Providing a Video Testimonial

Yes

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

Yes

Consent to Share Treatment Information with Donor Organization

I authorize Amen Clinics to share information about my care and treatment, including personal health information (PHI), with the donor or foundation providing financial support for my services. This may include updates on my clinical progress, treatment plan, evaluation results, and general outcomes.

I understand that this information is being shared solely for the purpose of keeping the donor informed of my participation and progress in treatment. I also understand that the donor is not permitted to further share, use, or distribute my PHI beyond this intended purpose.

This consent is voluntary and may be revoked at any time by submitting a written request to Amen Clinics.

Patient Assistance Fund Nemec Abbott Foundation

Submitter Information

Patient Information

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

Consent to Share Treatment Information with Donor Organization

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Patient Assistance Fund
Nemec Abbott Foundation