Subsidy Application

This information is being collected for the sole purpose of this application.

The information included in this application will not be shared with anyone outside of Christian Counselling Ottawa and will only be stored in the client’s file.
Subsidy will be given to those who generally meet these two criteria:

Household income below $40,000
No insurance benefits coverage

Following reception of the application, you will be contacted by our Intake Coordinator to establish the session fee amount which will then be sent to our subsidy committee for approval. If approval is granted, a Subsidy Statement of Understanding will be sent to you with the details listed for your signature.

This will be returned to the Intake Coordinator to be put on your file.

Subsidy Application

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Province Postal Code

Email(Required)

Phone(Required)

Total Household Income(Required)

Total Income includes all people who are contributing to the finances of the household.

# of people supported by that Income(Required)

Please upload an image/pdf of last year's Income Tax Assessment or three previous pay stubs

Max. file size: 2 MB.

Please indicate your proposed payment per session

Please provide a detailed reason for seeking therapy

This helps us appropriately match you with the most appropriate therapist, if approved.

Declaration Statements

I understand that renewal of subsidy is not guaranteed past the initial agreed upon sessions.

I understand that the subsidy program is funded by generous donors. If my income changes it is my responsibility to inform my therapist as soon as possible so the subsidy amount can be readdressed.

I confirm that all information provided is correct to the best of my knowledge and that ticking this box acts as my digital signature.

Date(Required)

Subsidy Application

Subsidy Application

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