SMart Center Financial Assistance Program Application

For individuals and families seeking financial support for SMart Center services including services from Counseling & Assessments at the SMart Center. Outside organizations are not eligible for financial assistance rates.

PROCEDURES

All income will be verified annually for all families who wish to be eligible for reduced program fees.
Acceptable means of income verification are:
- Pay stubs for everyone who works in the household
- Most recent years tax form AND/OR annual income verification
Any changes in income or family size MUST be reported to the SMart Center immediately. These changes include:
- Family Income Changes:
  - Obtaining employment, becoming self-employed
  - Loss of employment, loss of business
  - Change in wages - increase or decrease
  - Becoming eligible for or ineligible for: unemployment, workers comp., disability, SSI, SSD, child support, retirement benefits
  - Bankruptcy filings
  - Becoming a landlord, manager, or caretaker
  - Begin payment or receipt of child support
  - Change in responsibility for account
- Family Size Changes:
  - Marriage
  - Change in domestic partner living arrangements
  - Divorce or separation
  - Birth
  - Death
  - Adoption
- Name, address, and phone changes

The definition of “Family” for the SMart Center is: Mother, Father, Children, Significant Other, Spouse, and any dependent adult or child who is supported by the family unit and benefits from the combined household income. Roommates do not qualify as “Family.”

HOW TO APPLY

Complete and submit the application in its entirety along with the three following means of income certification and circumstance for our board to review (all information is kept confidential):

TWO recent pay stubs for everyone who works in the household,
Current income tax forms (page that verifies total annual income),
Brief Letter stating your situation.

If you prefer to mail your application, please print this form along with your three required income certifications and send to:

SMart Center
ATTN: Financial Assistance Application (Confidential)
6044 Creekside Drive
Flourtown, PA 19031

Please allow 2 weeks for a member of our team to review your application. For questions or further information about fees, please contact us at 215-887-5748 or by email info@smartcenter.us

Patient's First Name *

Patient's Last Name *

Patient Date of Birth * +

Gender *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

How many members are in your household? *

Please select the category that best fits your family's income: *

Pay Stub 1 (income verification) *

Pay Stub 2 (income verification) *

Pay Stub 3 (income verification)

Pay Stub 4 (income verification)

Income Tax Form *

Income Tax Form

Letter/message to the SMart Center explaining your situation: *

What services are you interested in receiving financial assistance for? Please check all that apply: *

CommuniCamp™ Intensive Group Treatment & Parent Training Program for Selective Mutism, Social Anxiety, and Extreme Shyness

Individualized Intensive Treatment & Consultations for Selective Mutism

Mental Health Counseling

Assessments: ADHD, Autism, Speech & Language, Psychoeducational/Neuropsychological

If you're applying for CommuniCamp™, please enter the month/year of the session. Otherwise, enter "N/A" below *