Patient Assistance Fund Application - Change Your Brain Foundation

Patient Assistance Fund
Internal Request

Please fill out the application below to apply.

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

Patient Name(Required)

First Last

CID #(Required)

Clinic Location(Required)

Referring Physician/Clinician Name(Required)

First Last

What services are being requested?(Required)

If this request is for follow-up appointments, how many are being requested?(Required)

Please provide a brief explanation of why these services are being requested(Required)

How will these additional services support the patient’s treatment plan and outcomes?(Required)

Total cost of requested services(Required)

On a scale of 1–10, how motivated is the patient to participate in and complete these services?(Required)

Please enter a number from 1 to 10.

1 = low motivation, 10 = highly motivated

Is there anything else the Foundation should know regarding this request?(Required)

Date(Required)

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