Apply-Therapy Assistance Program - Grand Rapids Pride Center

Co-Pay Assistance Program

The Co-Pay Assistance Program is designed to cover the co-payment costs up to $40 per sessions for up to 12 sessions. Program participants will usually have insurance that covers some of the cost of therapy, and also need assistance in paying their required co-pay.

Therapy Assistance Program

The Therapy Assistance Program is designed to connect LGBTQ+ individuals with local safe and affirming therapists. The Grand Rapids Pride Center Therapy Assistance Program will pay for up to five (5) therapy sessions for an eligible applicant for this program year. If more than 5 sessions are needed, the therapist and Health Equity Program staff will be available to assist with in finding further resources. Program participants who are not already working with a therapist will have the opportunity to review a list of vetted therapists participating in the Therapy Assistance Program, and choose their top two preferred therapists. We will make every effort to connect participants with one of their preferred therapists depending on scheduling availability.

Please review and select from the TAP list of available therapists (click to open in new tab).

First Therapist Choice*

Please select your first choice therapist from the PDF of available TAP therapists, linked above; or "No Preference".

Second Therapist Choice

Please select your second choice therapist from the PDF of available TAP therapists, linked above; or "No Preference".

(Optional) Is there anything you'd like us to know to help connect you with a suitable therapist?

Therapist Name*

Therapist Address*

Street Address Address Line 2 City State ZIP Code

Therapist Email

Therapist Phone Number*

What is your current insurance co-pay for therapy?

Is your co-pay due at time of service, or can you receive an invoice?

Co-pay due at time of service
I can receive an invoice for my co-pay
Not sure

The Grand Rapids Pride Center will provide you with a letter to present to your therapist about this program, asking that they send an invoice for your co-pay to GRPC. The invoice should be submitted as soon as possible after service delivery, and will be paid directly to the therapist / agency via check or online portal. Please acknowledge.*

I acknowledge.
This may be a problem. (Please complete application and a GRPC staff member will reach out to you.)

(Optional) Is there anything you'd like your therapist to know before you meet them?

Do you have access to video chat for tele-therapy?*

Yes, I can access a phone or computer with a camera and microphone, and WiFi/internet
No, I can't use video chat; I want to access therapy by phone
I need help with this

Please describe any other access barriers you may be facing:

(E.g. transportation issues, no internet access, parents restricting your use of health insurance, etc..)

Co-Pay Assistance Program Acknowledgement of Participation*

I acknowledge that by participating in this program, the Grand Rapids Pride Center is agreeing to subsidize the co-pay costs up to $40 per session for up to twelve (12) therapy sessions for the applicant for this program year, whether that be face-to-face therapy or tele-therapy. I acknowledge that if I attend therapy sessions beyond the agreed-upon number, I will be responsible for paying for them myself.

Note: Keep track of how many therapy sessions you attend! Contact your therapist or Proud To Be Healthy staff for further assistance.

Co-Pay Assistance Program Release of Liability*

As a participant of this program, I agree to not hold the Grand Rapids Pride Center and any of its staff, Board of Directors, interns and/or volunteers liable for any incidents or circumstances that arise out of the clinical relationship between the program participant and the therapist and/or agency. The Grand Rapids Pride Center is not responsible for any actions, statements, clinical recommendations or diagnoses made by the therapist and/or agency.

Therapy Assistance Program Acknowledgement of Participation*

I agree that by participating in this program, the Grand Rapids Pride Center is agreeing to connect participants with a therapist and pay for up to five (5) therapy sessions for the applicant for this program year, whether that be face-to-face therapy or tele-therapy. Grand Rapids Pride Center) per session. I acknowledge that if I attend therapy sessions beyond the agreed-upon number, I will be responsible for paying the full cost of those additional sessions myself.

Therapy Assistance Program Acknowledgement of Participation*

I agree that by participating in this program, the Grand Rapids Pride Center is agreeing to pay for up to five (5) therapy sessions, whether that be face-to-face therapy or tele-therapy, PROVIDED THE THERAPIST AGREES to participate in the Therapy Assistance Program for a specific amount of compensation (set by the Grand Rapids Pride Center) per session. I acknowledge that if I attend therapy sessions beyond the agreed-upon number, I will be responsible for paying the full cost of those additional sessions myself.

Therapy Assistance Program Release of Liability*

As a participant of this program, I agree to not hold the Grand Rapids Pride Center and any of its staff, Board of Directors, interns and/or volunteers liable for any incidents or circumstances that arise out of the clinical relationship between the program participant and the therapist and/or agency. The Grand Rapids Pride Center is not responsible for any actions, statements, clinical recommendations or diagnoses made by the therapist and/or agency.

Therapy Access Acknowledgement of Participation*

I agree that by participating in this program, the Grand Rapids Pride Center is agreeing to make every effort to connect me with an affirming therapist. I acknowledge that any additional non-financial access issues or barriers will be addressed on a case-by-case basis.

Therapy Access Release of Liability*

As a participant of this program, I agree to not hold the Grand Rapids Pride Center and any of its staff, Board of Directors, interns and/or volunteers liable for any incidents or circumstances that arise out of the clinical relationship between the program participant and any therapist and/or agency. The Grand Rapids Pride Center is not responsible for any actions, statements, clinical recommendations or diagnoses made by any therapist and/or agency.

Information Release

Release of information between your chosen therapist and the Grand Rapids Pride Center, for the purpose of care coordination:*

By checking this box, I agree that my therapist's office may share patient information gathered by the agency / therapist to allow us to coordinate care together and to pay for eligible therapy or co-pay costs.

Typing your name here represents your signature:*

Comments

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