GAP Applicant Form

Emergency - Help Right Away

If this is an emergency, call:

24/7 Crisis Line: 1-800-642-1525
911

We're excited about your interest in the GAP program! The Grant Assistance Program, or GAP Fund, was designed to empower Rock County residents to prioritize their mental health by significantly lowering the cost of counseling services.

Applicant Information

Date

First Name

Last Name

Phone Number

Email Address

Do you live in Rock County?

Yes No

Files Upload documentation or email to: gapcontact@luv1luvall.org

Add file

Please upload a file

Are you interested in the GAP grant due to having high insurance deductibles?

Yes No

Upload documentation or email to: gapcontact@luv1luvall.org

Add file

Please upload a file

Existing Programs Awareness

There are existing programs out there that may be able to help you. We want to make sure you are aware of these programs and determine if you would be eligible for any of them. Even if you are eligible for any of these other programs, if the counselor you want to see isn't covered, you may still be able to get a GAP grant. The next few questions will focus on screening for these other programs.

Employee Assistance Program Do you currently work for a company that offers an EAP (Employee Assistance Program)?

Yes

Do you have any EAP visits remaining?

Yes

Is the provider you want to see on your employer's EAP provider list?

Yes

Receiving or Eligible for Medicaid? Are you receiving or would you be eligible for Medicaid? To qualify for Medicaid in Minnesota, most people must have income below certain amounts. 18-year-olds (and older) living with their parents can apply for Medicaid independently as long as their parents don't claim them on taxes.

Yes

Is the provide you want to see taking Medicaid?

Yes

Sliding Fee Scale Some people seeking counseling may qualify for a sliding fee scale for services at SWMHC based on having income below certain levels. The income guideline are based on Household size. 1-income above $29,161 2-income above $39,441 3-income above $49,721 4-income above $60,001 Would this apply in your situation?

Yes

Is the provider you want to see at SWMHC?

Yes

MnFIRE Assistance Program Are you or anyone in your family a firefighter?

Yes

MnFIRE Assistance Program offers five no cost counseling sessions to firefighters and their families. Do you qualify for this? https://mnfireinitiative.com/hhap/

Yes

Is the provider you want to see approved for MnFIRE

Yes

LSS Core Are you or anyone in your family in the military or a Veteran?

Yes

LSS Core provides free counseling sessions for military members, Veterans, and their families. Is the provider you want to see approved for LSS? https://mn.gov/mdva/assets/2018-10-10-core-brochure_tcm1066-355412.pdf

Yes

Sexual Abuse Survivor Some people seeking counseling are survivors of sexual abuse. Would this apply to your situation?

Yes

SOSA's survivor therapy program offers 12 free sessions. Is the provider you want to see approved for SOSA? https://sosatogether.org/therapy

Yes

HELP Program Services Some people may be seeking support after foster care or adoption. Would this apply to your situation?

Yes

Services are free and available. Is the provider you want to see in the HELP program? https://www.fosteradoptmn.org/permanency-services/help_program_overview/

Yes

Farmer Resources Are you a farmer?

Yes

MN Agricultural Mental Health Specialist Ted Matthews: 320-266-2390; Monica McConkey: 218-280-7785 https://r5dc.files.wordpress.com/2023/05/mentalhealth_brochure2023_web.pdf

Yes, I've heard about this program

No, I haven't heard about this program

Minnesota Farm and Rural Helpline https://www.mda.state.mn.us/minnesota-farm-rural-helpline

Yes, I've heard about this program

No, I haven't heard about this program

Crisis Services at SWHMC 24/7 Do you know that you can access crisis services at Southwestern Mental Health Center for up to two weeks at no cost?

Yes

No, Crisis Hotline 1-800-642-1525

Student (or parent of a student) Are you a student, or parent of a student at a school in Rock County?

Yes

Did you know that you can access free counseling services through Greater Minnesota at school?

Yes

Prefer to access something outside of school

University of St. Thomas Telehealth Free Counseling Would this be an option for you?

Yes

Free telehealth counseling services by psychology students at the masters and doctoral levels. Potential clients who are uninsured or under-insured are prioritized. Would that be an option for you?

Yes, contact Interprofessional Center at 651-962-4820

https://www.stthomas.edu/ipc/psychservices/counselingservices/

Walk-In Counseling Center Free Counseling services with no appointments. Walk-in is located in Minneapolis, but telehealth would be an option for Rock County residents. Are you aware of this program?

Yes

Walk-In Telehealth Appointment at Counseling Center Ongoing sessions with the same counselor may not be possible. Would that be an option for you?

Yes, visit https://walkin.org

GAP Contribution That's the end of the questions about other existing programs. We have one last GAP requirement to cover. Remember how the GAP fund is designed to help by significantly lowering the cost of counseling sessions? If you are approved for a GAP grant, you would be expected to pay $25.00 to your therapist at the time of each session. The grant would cover the rest for up to 10 sessions. Do you agree to pay the provider a $25 contribution at the time of each visit?

Yes, I agree to pay the provider a $25.00 contribution at the time of each visit

No, I do not agree to pay the provider

Other

Have you already selected your provider?

Yes

Providers Name

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