APPLICATION FOR REIMBURSEMENT (FOR APPLICANT) – FORM C APPLICATION FOR REIMBURSEMENT (FOR APPLICANT) - FORM C All fields marked with * are mandatory. Please note the following with respect to this form: This form is to be completed by the applicant Please complete this form if you have paid out-of-pocket for therapy/counselling costs and/or incurred costs directly as a result of attending therapy/counselling in accordance with the College’s Policy, and are seeking reimbursement. This form can be submitted as part of your initial application for funding-Form A or can be submitted after you have been approved for funding. Invoices or receipts that list the therapy or counselling costs and session dates must be included with this form. The College reserves the right to refuse requests that are not supported by proof of payment and reserves the right to verify all information submitted. Applicant Information First Name *: Last Name *: Pronoun *: Home Address: Suite/Apt: City/Town: Province: Postal Code: Email Address *: Phone Number: Type of phone number provided above: HomeWorkMobile Do you have other sources of funding available for this claim?YesNo Other sources of funding, such as OHIP or a private insurance plan, must be used before claiming reimbursement for past costs incurred. If your coverage does not pay the full amount of the therapy or counselling sessions, the College would pay the remaining balance. Source of funding or name of private insurer: Name of Therapist or Counsellor Who Provided Services: First Name of Provider (if known): Last Name of Provider (if known): Pronoun: Home Address: Suite/Apt: City/Town: Province: Postal Code: Telephone: Email Address of Provider (if available): Start Date of Therapy or Counselling (if applicable): Details about the therapy or counselling: Was this therapy, counselling or both?: Please provide the information noted below: Date of Service Total Cost Description of Invoice / Upload a copy By clicking “Submit” I hereby confirm that I am the person identified on this form. Note: Please check your junk email folder if the confirmation email does not appear in your inbox.
