Financial Aid Form – Psyvo Health

Apply for Financial Aid

Psyvo Health offers need-based financial aid covering up to 100% of costs for low-income families. If you do not qualify for a full waiver, you may still receive psychoeducation discount of up to 80%. Please note that participants are responsible for paying any remaining balance or fees not covered by the award.

Referring Organization Name

First Name

Last Name

Share a bit about yourself

How many people currently live in your household?

How many of these household members are financial dependents?

What is your total annual household gross income?

Provide a copy of your most recent tax return?

What is your current employment status?

Do you currently receive any form of public assistance?

Email Address

Phone Number

Preferred method of contact

Address

Address Line 2

City

State

Zip Code

If you are in an emergency dial 911 or 988 for crisis. This number is to save lives by serving anyone, at any time, from anywhere across the nation.