APPLICATION FORM FOR FUNDING FOR THERAPY OR COUNSELLING (FOR APPLICANT) – FORM A APPLICATION FORM FOR FUNDING FOR THERAPY OR COUNSELLING (FOR APPLICANT) - FORM A All fields marked with * are mandatory. Applicant Information First Name *: Last Name *: Pronoun *: Home Address: Suite/Apt: City: Province: Postal Code: Phone Number: Email Address *: Type of phone number provided above: HomeWorkMobile Therapist or Counsellor Contact Information (if known) *Please note that you do not need to have the name of a therapist or counsellor at the time of applying for funding. If you already have a therapist or counsellor, please note them below and the College will send them the relevant form to submit to the College. First Name of Provider (if known): Last Name of Provider (if known): Pronoun: Address: Suite/Apt: City: Province: Postal Code: Telephone: Email Address of Provider (if available): Start Date of Therapy or Counselling (if applicable) Is this therapist/counsellor a regulated professional in Ontario? YesNoI don't know If Yes, what profession (e.g., College of Registered Psychotherapists)? Are the services of this therapist/counsellor covered by OHIP or another insurer? YesNoI don't know Do you intend to request reimbursement for out-of-pocket therapy or counselling costs? YesNoI don't know If yes, please upload a copy of the receipt(s): Acknowledgements I acknowledge and confirm that: I have no personal or family relationship or conflict of interest with the therapist or counsellor. Funding shall be paid only to the therapist/counsellor for therapy or counselling related to this application. If the therapist/counsellor is not regulated, they are not subject to professional discipline by any regulatory body. To the best of my knowledge, the therapist/counsellor has never been found guilty of misconduct of a sexual nature. The College may deduct any other funding I receive for therapy or counselling. The maximum amount payable is $5000.00. No duplicate payments will be made. I will notify the College if OHIP or private insurance covers part of the cost. Cancellation or late fees are my responsibility. By checking this box, I confirm the information provided above is accurate to my knowledge and confirm the acknowledgements listed immediately above. I agree to allow the Ontario College of Social Workers and Social Service Workers to contact me and my chosen Therapist or Counsellor as necessary, to process my application for funding. 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.
