DCF Financial Assistance Application Your Name * First Name Last Name Email * Phone (###) ### #### City of Residence * Who are Services for? * First Name Last Name Age * Gender * Female Male Ethnicity * Relationship to person receiving services? * Reason for counseling * What is the family’s financial hardship? * I acknowledge that while I am applying for financial assistance, I understand that the DCF emphasizes the importance of individual participation in the financial responsibility for mental health services. I accept that DCF will not cover the full cost of these services, and I agree to contribute to the extent required. * I agree Thank you!
