Hardship Request Form

The North Central Behavioral Health Board recognizes that unexpected financial circumstances can make it difficult for individuals and families to afford needed behavioral health services.

The Hardship Request Form allows eligible clients to request additional financial consideration when circumstances such as a serious family event, disaster, domestic violence, increased caregiving expenses, or another significant financial hardship affect their ability to pay.

Clients requesting hardship assistance should complete the Hardship Request Form and provide any supporting documentation related to the financial hardship.

The form requests information such as household income, number of dependents, the circumstances contributing to the hardship, and the services expected to be provided using Board funding.

Completed forms should be submitted according to the instructions provided by the client’s service provider. Submission of a hardship request does not automatically guarantee approval.