Client Application

Name

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Place of Employment

Total Monthly Income Contributed by you

Number of Household Members Supported by this income

Assistance Received

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

Please list the amount of your major monthly expenses

Rent, Mortgage, Utilities, Car Payments, Car Insurance, Health Insurance Premiums, Child care, Debt and Student loans

Please describe the general reason you are seeking counseling at this time

Income verification

Click or drag files to this area to upload. You can upload up to 4 files.

Referred by

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

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.
My protected health information could be utilized for coordination of benefits.
I understand that Pier 34 is a foundation that reimburses providers for mental health services, that have beenrendered following approval, and our organization is not an insurance company.

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