FREE TO BE MINISTRIES

Grace Church Bath
Care Coverage Assistance Form

Free to Be & Grace Church Bath - Coverage Care Assistance Form

What is the Grace Church Bath Campus (GCBC) Client's name?

Is this client a Grace Church Bath (GCBC) Staff Member or Congregant?

Staff Member

Congregant

What is the Free to Be Ministries (FTB) Assigned Counselor's Name?

Number of Completed GCBC Covered Sessions?

What tier of additional coverage is the FTB Counselor advocating for their client?

Tier II: Additional coverage beyond the first 3 covered visits (visits 4-6) - automatic approval

Tier III: Additional coverage beyond the first 6 covered visits (visits 7-10) - will need GCBC approval before instating, GCBC may reach out to check in with client

Tier IV: Additional Coverage beyond the first 10 covered visits (visits 11-15) - will need GCBC approval before instating, GCBC may reach out to check in with client

Tier V: Additional Coverage beyond the first 15 sessions (Visits 16+) - Will need GCBC approval before instating, GCBC may reach out to check in with client, Campus Pastor will be Notified

As thier FTB Counselor, I am advocating that both statments are true for this client (if yes, check both)

This client is making progress in their work and would greatly benefit from additional sessions

This client has a financial harship and cannot afford to pay for futher sessions beyond the copay.

Referring Grace Pastor or Leader (if known)

Additional Comments

Thanks for submitting! Please note coverage beyond Tier I will need approval from Grace Church to be implemented. Expect to hear within two weeks of form submission.

FREE TO BE MINISTRIES

Grace Church Bath Care Coverage Assistance Form

Free to Be & Grace Church Bath - Coverage Care Assistance Form

Grace Church Bath
Care Coverage Assistance Form