Steps to Financial Assistance Consideration

Fill out this entire financial assistance form accurately and completely
Submit completed form
You will be notified whether your financial assistance application was accepted or rejected within 45 days of submission

Income Verification Must Be Attached For Consideration

Frequently Asked Questions

What is considered proper income verification?

Answer: Recent Paycheck Stubs, a copy of last year’s IRS Tax Statement or SSI Allocation Form, Access Card, proof of collection of Food Stamps, and documentation of special housing arrangement such as Domestic Violence Shelter.

How quickly can I expect to hear back from Pier 34 about my financial assistance request?

Answer: It generally takes 45 days. You will be notified by way email of the results as soon as your application is processed.

What determines the amount of financial assistance I may be awarded?

Answer: Pier 34 uses a standardized income scale that determines whether the applicant will receive the assistance. Monthly income and number of household members are considered in the process. Using this scale provides a fair and consistent process in awarding assistance.

If I am approved, how much will I have to pay at each of my sessions?

Answer: If you are awarded the assistance, you will be expected to pay $15 per session. You will receive up to six sessions.

FINANCIAL ASSISTANCE AWARDS ARE VALID FOR ONE YEAR STARTING THE DATE OF YOUR APPROVAL. AFTER ONE YEAR, A NEW APPLICATION WITH NEW INCOME VERIFICATION WILL NEED TO BE COMPLETED.

Client Application

We are no longer able to approve assistance for Sooner Care recipients with mental health benefits included in your plan. Please contact Amanda at: info@pier34.org or your provider for additional resources.

Full Name*

Street Address*

City, State, Zip Code*

Email*

Phone*

Date of Birth*

day

month

year

Place of Employment*

Total monthly income contributed by you*

Number of household members supported by this income*

Total monthly income contributed by spouse and/or other household members*

Assistance Received*

Family Members to Be Included in the Sessions and Date of Birth

Please tell us more about why you are in financial need at this time*

Please list the amounts of your major monthly expenses: Rent, Utilities, Car Payments, Car Insurance, Health Insurance Premiums (this will not disqualify you for assistance), Child Care, Debt, and Student Loans*

Please give us a general explanation of why you are seeking counseling at this time*

Upload Income Documentation

Referred by*

Upon completion and submission of this application, I certify that:

1.The information supplied therein is true, accurate, and complete to the best of my knowledge. Pier 34 will immediately revoke any granted assistance if false information is provided in this application.

2. My protected health information could be utilized for coordination of benefits.

3. I understand that Pier 34 is a foundation that reimburses providers for mental health services, that have been rendered following approval, and our organization is not an insurance company.

If you are in need of assistance with this submission please contact Amanda at:

info@pier34.org

Apply