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Illuminating paths to hope, healing, and support to ensure no one feels alone in their struggles

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Arielle's Light

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text TALK to 741741

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Financial Assistance Application

Contact Information

Preferred Pronouns

He/Him; She/Her; They/Them; Etc...

First name*

Last name*

Mobile Phone*

Email*

City*

State*

Preferred Method of Contact*

Phone Call

Text

Email

Birthday*

Month

Day

Year

Mental Health Needs

Have you previously received therapy or counseling services?*

Yes

No

Are you currently receiving therapy or counseling services?*

Yes

No

If yes, would you like to continue with your current therapist?

Yes

No

What are the primary mental health challenges you are facing? (e.g., anxiety, depression, trauma, grief, stress)

Do you prefer virtual (online) or in-person therapy?*

Virtual

In-Person

No Preference

Therapist Preferences

Would you like to choose a therapist from Arielle’s Light network?*

Yes

No, I already have a therapist I’d like to continue with.

If you have a preferred therapist, please provide their details:

Therapist's Name:

Therapist's Contact Information:

Financial Assistance

What is your current financial situation?*

Employed Full-Time

Employed Part-Time

Unemployed

Student

Other

Do you have health insurance that covers mental health services?*

Yes

No

If yes, does your insurance fully or partially cover therapy sessions?

Fully Covered

Partially Covered

Not Covered

Are financial barriers preventing you from accessing therapy right now?*

Yes

No

What is the maximum amount you can afford per individual therapy session? (It’s completely okay to put $0 if you’re unable to contribute at this time.) *

$_______ per session

Additional Information

How did you hear about Arielle’s Light?*

Social Media

Friend/Family Member

Therapist Referral

Online Search

Other

Is there anything else you’d like us to know about your situation or needs?

Agreement and Consent

By checking the boxes below and submitting this application:

I confirm that the information provided is accurate and truthful to the best of my knowledge.

I consent to communication from Arielle’s Light via my preferred contact method.

I understand that all information provided will remain confidential.

I understand that Arielle’s Light will not have access to therapy session details, as confidentiality is protected between the therapist and client.

Financial Assistance Coverage

By checking the boxes below and submitting this application:

I understand that Arielle’s Light will initially cover the cost of up to 4 individual therapy sessions.

I understand that any additional sessions may be covered with approval, but not guaranteed.

Disclaimer

At Arielle’s Light, our role is to facilitate access to licensed mental health professionals by providing financial assistance for therapy sessions. We do not provide therapy services directly, nor do we guarantee specific outcomes or resolutions to mental health concerns.

Limited Role: Our responsibility is limited to financial assistance and facilitating connections between clients and therapists within our network.
Responsibility for Services: The therapist-client relationship is independent of Arielle’s Light. Any issues, concerns, or disputes regarding therapy services, treatment approaches, or outcomes must be addressed directly with the therapist.
No Guarantees: Arielle’s Light does not guarantee the effectiveness of therapy, the resolution of mental health struggles, or any specific results from sessions funded through our program.

By participating in our program, therapists and clients acknowledge and accept this limitation of responsibility.

Signature*

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Date picker*

Parent/Guardian Signature (if applicable)

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Date picker

Arielle's Light

™

Contact us

hello@arielleslight.org

Arielle’s Light is a 501(c)(3) nonprofit organization.

EIN: 33-2597630.

Donations are tax-deductible to the extent permitted by law.

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