Apply to the Stronger Minds Fund

1Applicant information

First name *

Last name *

Date of birth *

Email address *

Phone number *

Street address *

Apt / unit (optional)

City *

State *

ZIP code *

2Assistance request

Explain the expense and how assistance would help you access or continue care. Please do not disclose diagnoses, therapy notes, or unnecessary medical history.

Provider or practice name *

Provider address and contact information

Provider street address *

Provider city *

Provider state *

Provider ZIP code *

Provider phone number (optional)

Provider email address (optional)

Provide at least one provider contact method: phone or email.

Assistance type * (select all that apply)Therapy or counseling expensesIntake or initial appointment expensesMental health medication expensesOther eligible mental health-related expenses

Amount requested (USD) *

Current care status *Currently receiving mental health servicesIntake scheduled or in the process of beginning servicesSeeking care but have not yet established services

What is your approximate total annual household income before taxes? *

Total household income before taxes, not take-home pay. You may choose “Prefer not to answer.”

Which circumstances are making it difficult for you to afford the requested mental health care? Select all that apply. *I do not have health insurance.I have insurance, but my deductible or out-of-pocket costs are too high.My insurance does not cover the service or expense I need.I am experiencing a reduction in income or unemployment.My essential living expenses leave limited money for mental health care.I am experiencing an unexpected financial hardship.I am experiencing another financial barrier.Prefer not to answer.

Is there anything else you would like the review team to understand about your financial circumstances or request? (optional)

0/2,000 · Do not include diagnoses, therapy notes, or unnecessary medical details.

3Supporting documents (optional)

Upload only documents relevant to your request. Redact unnecessary personal or medical information, including diagnoses, therapy notes, and unrelated medical history, wherever possible.

Supporting documentation

Bills, invoices, estimates, pharmacy bills, or other relevant proof of the expense.

PDF, JPG, JPEG, or PNG · up to 10 MB each

Care status documentation

Proof of current care or a scheduled intake, when available. Not required if you have not yet established care.

PDF, JPG, JPEG, or PNG · up to 10 MB each

4Payment preference

If your application is approved, how would you prefer to receive assistance? *ACH bank transferPaper check mailed to me

5Required acknowledgments

I certify that the information provided is accurate and complete to the best of my knowledge.

I authorize The Broski Foundation, Inc., when reasonably necessary to evaluate this application, to contact my identified provider or practice solely to verify relevant care or expense information. This does not authorize requests for my diagnosis, therapy notes, or detailed medical history.

I understand that my information will be used to evaluate and administer my request and may be accessed by authorized individuals involved in that process. Submitting an application does not guarantee assistance.

I understand that knowingly providing materially false information or intentionally misusing assistance may result in denial, cancellation, or a request for repayment, subject to applicable policies and law.