Aimee Howard Foundation: Empowering Young Minds Through Accessible Therapy

About the applicant

Tell us who this application is for. If you are applying on someone else’s behalf, enter their details here.

Applicant's first name *

Applicant's last name *

Date of birth *

We support young people aged 13 to 25.

Email address *

Phone number *

Country of residence

Home address

Who is filling in this form?

Your name *

Your relationship to the applicant *

Emergency contact

Someone we can reach if we ever have a serious concern about the applicant’s safety.

Full name

Relationship to applicant

Phone number

Email address

Mental health

Share as much or as little as feels comfortable. Everything here is confidential.

Please describe the current mental health struggles *

Has there been a diagnosis of any mental health conditions?

YesNo

If yes, please provide the diagnosis

Any medication currently being taken for mental health?

YesNo

If yes, please list the medications

Currently receiving therapy?

YesNo

Current therapist (if there is one)

Therapist's name

Therapist's phone number

Therapist's email address

How do you believe receiving therapy will impact their mental health and overall well-being?

Financial situation

This helps us understand need. We do not share these details outside our review team.

Currently employed?

YesNo

If yes, please provide details about the job (title, employer, income)

Any dependents?

YesNo

If yes, how many dependents?

Please list any current financial obligations (e.g. rent, utilities, debts)

Have you applied for financial aid from any other sources?

YesNo

If yes, please provide details about other financial aid applications

Is there medical aid cover?

YesNo

Medical aid provider

Plan / option name

Please explain why financial aid for therapy is needed *

Verification and consent

Last step. These confirmations let us verify the application and arrange care.

Upload a copy of the applicant's ID or identification document

Accepted: PDF, JPG or PNG, up to 10MB. Documents are handled confidentially and are sent only to our secure case-management board.

I certify that the information provided in this application is true and accurate to the best of my knowledge. *I understand that providing false information may result in the denial of this application for financial aid. *I agree to allow the Aimee Howard Foundation to contact the therapist and/or healthcare providers to verify information related to this application. *

This application includes health information. Our privacy policy explains what we collect, who can see it, and how long we keep it.

Step 1 of 5

Apply for Help

About the applicant

Emergency contact

Mental health

Financial situation

Verification and consent