Counseling Services Program Application : Support & Resources : National Bleeding Disorders Foundation

The Counseling Services Program is part of the Idaho Chapter of the National Hemophilia Foundation’s (NHF Idaho) continuing effort to improve the quality of life of individuals and families affected by bleeding disorders by access to counseling services. NHF Idaho has partnered with, Eastern Idaho-based, Kristopher L. Walton & Associates, LLC (KLWA) to provide tele-heatlth counseling services to our community members.

The program is now available and is funded for one year through a grant from the Hemophilia Alliance Foundation for a one-year period. More information about KLWA can be found on the internet at https://eastidahotherapy.com/.

Eligible applicants are individuals with a bleeding disorder or an immediate family member or designated caregiver of an individual with a bleeding disorder. If your application is approved, NHF Idaho will pay for up to four (4) one-hour sessions that may also be renewable upon submission of an additional request in coordination with KLWA. NHF Idaho will facilitate the funding of the program and follow all federal and state laws, to include HIPAA privacy standards. At no time will NHF Idaho request or obtain any specific clinical information from KLWA or any other provider, ever. Any information requested will be related to insurance coverage, if applicable, and the documented request for continued services as applicable.

Continued payment of counseling services is dependent upon the amount of funding available. NHF Idaho will never make a determination regarding the need for counseling services. This is between you and your KLWA provider.

This program is not intended to take the place of any current health insurance coverage you may have or any government program you may participate in, to include but not limited to Medicare or Medicaid.

This application is intended to obtain basic information on any health insurance coverage you may or may not have. The questions in this application are based solely to determine you or your child’s eligibility in the NHF Idaho Counseling Services Program and will not be used for any other purpose or shared with anyone except KLWA upon approval.

Name of Requestor

Enter name of person requesting counseling services.

First Name *

Middle

Last Name *

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Date of Birth

Month

Day

Year

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone Number (Required)

Alternate Phone Number (Required)

Email Address (Required)

Do you have internet access at home capable of video chatting?

Do you have a device capable of video chatting?

Are you able to commit to 4 one-hour meetings on four consecutive weeks or as recommended by the provided counselor?

Do you have a bleeding disorder?

Are you an immediate family member of an individual with a bleeding disorder with whom you live within the same household?

Do you currently have health insurance?

If No, please answer "N/A" for the next two associated questions.

Health Insurance Company Name (Required)

Name of Primary Insured (Required)

Are you enrolled an any other state or federal health insurance program? Do not include food, housing, or other assistance programs that are not provide health insurance or direct medical coverage.

If Yes, please specify below.

Other Programs Enrolled

I understand that the information contained within this application will be shared with the contracted therapy provider at KLWA as part of the referral process. I give my permission to share the information included in this form.

I understand that my participation will be known only to the NHF Idaho staff running the program and that at no time will any personal health information be shared between KLWA and NHF Idaho. Health plan remittance advice or explanation of benefits (EOB) associated with KLWA insurance claims, if applicable, will be shared by KLWA with NHF Idaho to comply with program requirements.

Name of Requestor (Required)

Relationship of Requestor

Self
Parent
Guaridan (Must have authority to act on behalf of individual who will be receiving services.)

eSignature of Applicant (Required)

Counseling Services Application

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