Counseling Hardship

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What is Counseling Hardship Program:

The Counseling Hardship Program provides short-term counseling assistance to individuals experiencing a mental health crisis who do not have insurance, have insurance coverage pending, or are on a waiting list for services. The program provides up to six counseling sessions to help you through the immediate crisis, remind you that you are not alone, and support you while you work with your counselor to develop a plan for long-term care. This program is intended to serve as a temporary bridge and is not a replacement for ongoing counseling.

First Name*

Last Name*

Email Address*

Phone Number*

Who is filling out this Application?*

Anyone age 18 or older must complete and submit their own application.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you give SEMO SP permission to contact you by phone, text message, or email about your application?*

Yes

Insurance/Counseling History

Have you previously received counseling through SEMO SP’s Counseling Hardship Program?*

If Yes: Please provide date hardship ended.

What is the earliest date you are available to begin counseling?*

Days Available for Counseling. (Check all that apply)*

Monday

Tuesday

Wednesday

Thursday

Friday

Times Available for Counseling (check all that apply)*

Morning

Afternoon

Evening

Which counseling format do you prefer?*

In Person

Telehealth (virtual appointments)

Either-No Preference

Are you currently receiving counseling or therapy?*

Are you currently on a waiting list to begin counseling or therapy?*

Yes, I am

No, I am not

If yes, which counseling provider are you on a waiting list with, and how long have you been waiting?

Have you contacted any other counseling providers or programs for help accessing or paying for counseling?*

Do you currently have health insurance?*

Does your health insurance require a copay for counseling sessions?

If Yes: How Much is your co-pay?

Who is your health insurance provider?

Health Insurance Member ID or Policy Number (if applicable)

Name of Primary Policyholder (the person who holds the insurance policy)

Is health insurance available through your employer or the primary policyholder’s employer?

Yes

Unknown

Upload Insurance Card (Optional)

Max. file size: 256 MB.

Employment

Are you currently employed?*

Name of Employer or Business (if applicable)

Employer’s Phone Number (if applicable)

Current Job Title or Position (if applicable)

Direct Supervisor’s Name and Job Title (if applicable)

Military

Have you, your spouse, or your parent/legal guardian ever served in the military?*

If yes, which branch of the military did you or your family member serve in?

Rank at Discharge (if applicable)

Military Service Start Date

Military Service End Date (if applicable)

Counseling Needs

Are you currently experiencing thoughts of suicide or self-harm?*

No, Not Currently

Yes, I am

Unknown

Are you currently in immediate danger or experiencing a mental health emergency?*

No, Not Currently

Yes, I am

Yes, I plan to reach out to 988 or 911 for help

Please note: Applications and responses are not monitored continuously. If you are experiencing suicidal thoughts, are in immediate danger, or believe you may harm yourself or someone else, please call or text 988, call 911, or go to your nearest emergency room for immediate assistance.

Are there any specific concerns, needs, or diagnoses you would like to address during counseling? (check all that apply)*

Please briefly describe why you are requesting financial assistance for counseling, including any current challenges or circumstances contributing to your need.*

What goals would you like to work toward during your counseling sessions?*

For example: managing stress or anxiety, coping with grief, improving relationships, or developing healthy coping skills. It’s okay if you’re unsure—your counselor can help you identify goals.

Do you have a plan for continuing counseling, if needed, after your approved sessions are completed?*

Yes

Unknown

Maybe

If Yes: Please briefly describe your plan or let us know if you need help exploring options.

Is there any additional information you would like to share to help us understand your needs when reviewing your application?*

Attendance Policy

By accepting assistance through the Counseling Hardship Program, you agree to attend all scheduled counseling sessions or cancel within your assigned therapy practice’s required cancellation period. Your first no-show or late cancellation will result in a warning from the SEMO SP Board. A second no-show or late cancellation will result in discontinuation of your assistance. A warning does not mean the missed appointment is free of charge. Each therapy practice determines its own no-show and late cancellation fees, which may apply beginning with the first missed appointment. You are responsible for any such fees charged by your therapy practice; SEMO SP does not cover these fees.

Consent, Acknowledgment and Privacy Statement

By checking this box and submitting this application, I confirm that I have read, understand, and agree to the Counseling Hardship Program’s requirements and attendance policy. I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that Southeast Missouri Suicide Prevention will use the information collected through this application only to review my application, determine eligibility, identify the counselor who can best meet my needs, coordinate approved services, and administer the Counseling Hardship Program. If I am accepted, the information reasonably necessary for these purposes will be shared with my assigned counseling provider so they may contact me and schedule an appropriate appointment time. Southeast Missouri Suicide Prevention will not sell, rent, trade, or provide my personal information to outside individuals or organizations for marketing, fundraising, or other unrelated purposes. Reasonable steps will be taken to protect my information from unauthorized access, use, or disclosure. Information may be shared when I provide permission, when required by law, or when there is an immediate concern for my safety or the safety of another person. Once I am assigned to a counseling provider, that provider will be responsible for protecting the privacy and confidentiality of my counseling records and will provide information regarding their privacy practices. I voluntarily consent to submitting this application, having my information reviewed and shared as described above, and being considered for assistance through the Counseling Hardship Program.

Counseling Confidentiality

Once your information has been provided to your assigned counselor, the counselor will not share the details of your sessions or personal discussions with Southeast Missouri Suicide Prevention. Your counseling sessions are confidential. Your assigned counselor may contact Southeast Missouri Suicide Prevention only when necessary to report a missed appointment, discuss whether the program or counseling placement is an appropriate fit, request additional resources or sessions on your behalf, or address another administrative need related to the Counseling Hardship Program. Your counselor may also contact the appropriate authorities if they believe you or another person is in immediate danger, or disclose information when required by law or their professional and ethical responsibilities.