Apply For Treatment Funding

New Start Foundation envisions a world where all Canadians can receive effective, equitable and timely mental
health and addiction treatment. Eligibility will be based on both clinical and financial need. Applicants must be
Canadian and over the age of 18.

Each applicant must:

1. Complete the financial application form
2. Complete the clinical assessment
3. Provide proof that all resources have been exhausted
4. Provide information regarding income, income tax, assets and bank information

Financial Application Form

Date Application Submitted:

Applicant Information (if different than payer/caregiver information below)

Name

Address

Date of Birth:

Telephone Number

Email Address

SIN

Program applying for

Adult in-patient treatment program (ages 19+) Digital Youth+ outpatient program (ages 18-26)

Payer Information

Payer Name

Marital Status

Single Married

Birth Date

Age

Number of Dependants

Current Address

Past Address

Payer Employment Information

Occupation

Current Employer

Employment Date

NEW START FOUNDATION IN-PATIENT TREATMENT FUNDING APPLICATIONDo you have health insurance through your employer?

Yes No

Health Insurance Information

Name of Insurer

Type of Plan

Treatment Coverage $

Health Spending Account Coverage $

Co-Payer Information

Co-Payer Name

Marital Status

Birth Date

Age

Number of Dependants

Current Address

Past Address

Co-Payer Employment Information

Occupation

Current Employer

Employment Date

Do you have health insurance through your employer?

Yes No

Co-Payer Health Insurance Information

Name of Insurer

Type of Plan

Mental health / addiction treatment coverage:

Health Spending Account Coverage: $

Income Statement

Combined Payer and Co-Payer Income Description

Line 150 from Notice of Assessment

T4 slip income

Investments

Other

Total Income $

Please list any other treatment the applicant is currently getting or has been had in the past three years:

Anything you would like us to know:

Does the applicant identify as a BIPOC or visible minority?

Yes No Prefer not to say

Are you requesting full or partial funding?

Full Partial

If partial, please suggest the amount of funding requested

Applicant Signature

Date

Please list any other treatment the applicant is currently getting in or has been had in the past three years

Anything you would like us to know:

Does the applicant identify as BIPOC or visible minority? (yes or no)

Are you requesting full or partial funding? (full) (partial)

If partial, please suggest the amount of funding requested:

New Start In-patient Treatment Funding Application

Application Process

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