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Patient Assistance Fund Application

*This application is available only for currently enrolled patients*

Preliminary Privilege Self-Screening Questions

(no responses needed here, just ponder your answers on your own)


Are you generally able to pay for your care out of pocket?

Are you employed and able to save some money towards the care you need?

Are you a citizen or documented immigrant?

Do you consider yourself healthy and able-bodied (i.e., not living with a chronic or long-standing illness)?

Do you identify as white, or do you experience white/light-skinned privilege?


If you answer Yes to many of these questions, you may consider making space for our trans siblings who mostly answered No.

However, you are still eligible to apply. These things will not disqualify you. 

Application Question Section

Please answer the questions below as best you can. There will be a section at the bottom for you to explain your situation in more detail in case these questions are difficult to answer in a way that adequately explains your situation.

Try your best, and explain further at the bottom if needed.

Birthday
Month
Day
Year

This can be however you would describe yourself (examples: caucasian, african-american, asian, latino, white, hispanic, black, brown, indigenous, POC, native american, prefer not to say, etc.).

Student Status
I am a college student currently enrolled in classes.
I am not a college student.
Military/Veteran Status
I am active duty military.
I am retired military.
I am in the military reserves.
I am a veteran, no longer active duty.
This does not apply to me.
Other
Disability Status- do you have any long-standing illness, disability, or infirmity that affects your ability to perform your basic activities of daily living (bathing, feeding, toileting, dressing, etc)?
Yes
No
Other
Have you applied for or are you receiving SSI/SSDI?
Applied
Receiving
This does not apply to me.
Do you currently have a full or part time job?
Yes
No
Other
Are you generally able to pay your costs of living each month? (Meaning food, clothing, housing/rent, water).
Yes
No
Are you homeless or experiencing housing insecurity?
Yes
No
Are you the primary caregiver for another individual (an adult or special needs child)?
Yes
No

*This question does not apply to children unless they are special needs.

Do you have some form of health insurance coverage?
Yes
No
Are you currently receiving Food Stamps/EBT benefits, Medicaid coverage, or another government assistance program for low income individuals?
Yes
No

This field isn't required, but you can use it to give more detail about your situation.

Available assistance is limited each month. Please select the number of months that would be most beneficial to your current situation if selected. Bear in mind we may not be able to meet the full request at times.
+3 months
+2 months
+1 month

End Of Questionnaire

Applications are reviewed by volunteers between the 20th and 30th of each month (all of your identifying information is removed from what they see). If selected, you will be notified once all applications for that time period have been reviewed. If not selected, you will also be notified, and we will keep your application for the following month’s application cycle unless you tell us otherwise. But we will not keep it beyond that point, and you would need to apply again if not selected for two months in a row.

*Occasionally, however, we may have smaller amounts available to distribute to those who aren’t selected for the main micro-grant options.

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