$

Affinity Healing Collective 501(c)(3) Funding Application

This application is for funding requests to support therapy services for clients or to provide funding for therapists to cover training or respite.

If you experience any issues with the online application or additional materials, send a direct message to info @ affinityhealingcollective.com.

> back to Funding Application landing page

Client Release of Information Form

Client Release of Information Form

Client Information

Therapist Information

Authorization to Release Information

I, 

authorize,

from, 

to release the following information to Affinity Healing Collective 501(c)(3) for the purpose of requesting funding to cover therapy sessions:

  • Demographic Information: Includes general information such as age, gender, race/ethnicity, and other non-identifiable demographic data.
  • Confirmation of Therapy Services: Verification that I am a current client 

Purpose of Release

This information is being released solely for the purpose of supporting an application to Affinity Healing Collective 501(c)(3) for funding to help cover therapy session costs.

Terms of Authorization

  • I understand that this authorization is voluntary and can be revoked at any time by submitting a written request. Revocation will not affect any information disclosed prior to the receipt of the written revocation.
  • I understand that information released under this authorization is protected under HIPAA regulations once disclosed to Affinity Healing Collective 501(c)(3).
  • This authorization will expire one year from the date of my signature unless otherwise specified.

Acknowledgment

By signing below, I acknowledge that:

  1. I have read and understand the terms of this release.
  2. I consent to the release of information as described above.
  3. I have been informed of my right to revoke this authorization.