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Request for SAJE Mental Health and Counselling Benefits

This form is completed by a young adult who currently has an Agreement with Young Adults, a Conditional or Unconditional Income Support Agreement, a SAJE Support Agreement, or who is supported under a SAJE Housing Agreement.

This form can be downloaded by clicking the PDF button bellow.

If you have a question about how to complete this form or may require an exception, please call SAJE Support at 1-866-623-3001 or email MCF.SAJE@gov.bc.ca

Your personal information will be collected for the purpose of determining eligibility for the Strengthening Abilities and Journeys of

Empowerment (SAJE) Mental Health and Counselling Benefit. The personal information requested on this form is collected under the

authority of Section 26(c) and (e) of the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or

disclosure of this information should be discussed with the Community Liaison/Quality Assurance Officer, toll free at 1-866-623-3001, PO Box

9776 Station Provincial Government, Victoria BC V8W 9S5.

First NameMissing or incorrect value

Middle Name

Last NameMissing or incorrect value

Preferred Name (if different from legal name)

Birthdate

Missing or incorrect value

Social Insurance Number (SIN)

Unit Number (if applicable)

Street AddressMissing or incorrect value

CityMissing or incorrect value

Province

Postal CodeMissing or incorrect value'A1A1A1' or 'A1A 1A1'

Email AddressMissing or incorrect value

Confirm Email AddressMissing or incorrect value

Do you consent to communicating and receiving information through email? Missing or incorrect value

Phone Number Missing or incorrect value

Can we leave a voice message on your phone? Missing or incorrect value

Can we text you? Missing or incorrect value

What type of mental health and wellness services are you requesting?Services from a Registered Psychologist, Clinical Counsellor or Social WorkerOther evidence-based therapeutic services to support mental health (examples: Art Therapy, Music Therapy, etc.)Cultural Healing Services (examples: Elders, Sweat Lodges, Land-based Healing, etc.)Missing or incorrect value

For more information about the services that are included or not included in the SAJE Mental Health and Counselling Benefit, please refer to the SAJE Mental Health and Counselling Benefit FAQ.

If you have indicated other evidence-based therapeutic services to support your mental health, please describe the services you are requesting (i.e. music therapy, art therapy, etc.). You do not need to provide information about your personal circumstances, diagnosis, or any other identifying information as to why you are requesting these supports.

If you selected Cultural Healing Services, please provide a brief, general description of the Cultural Healing Services, activities, or programming you will be participating in or receiving with these funds. You do not need to provide information about your personal circumstances, diagnosis, or any other identifying information as to why you are requesting these supports.

Alternately, a letter from your cultural healing service provider can be provided. This letter should be a brief, general description of the cultural healing services, activities, or programming you will be participating in or receiving with these funds.

You do not need to provide information about your personal circumstances, diagnosis, or any other identifying information as to why you

are requesting these supports.

If you have a copy of this letter, you can upload it below. You, or your practitioner, may also email this letter separately to MCF.SAJE@gov.bc.ca

Upload letter from cultural healing service provider:

Drag files here or use the button below. Remove File

Select File

Name of the individual providing servicesMissing or incorrect value

Profession (or service type) Missing or incorrect value

Agency Name (if applicable)

Unit Number (if applicable)

Street AddressMissing or incorrect value

CityMissing or incorrect value

Province

Postal CodeMissing or incorrect value'A1A1A1' or 'A1A 1A1'

Service Provider's Phone Number Missing or incorrect value

Service Provider's Email Address (if known)

Do you know whether the individual practitioner or the agency should be paid?IndividualAgencyDon't knowMissing or incorrect value

How much does each session cost? Missing or incorrect value

By signing this form, you are confirming that you are seeking the described services on a voluntary basis and are solely responsible for arranging for, assessing, and selecting the described services and service provider in accordance with your own judgement.

I acknowledge that a maximum of $1,500 is available per calendar year for eligible services and that I am solely responsible for paying for either ineligible services or for services that exceed $1,500 in the calendar year.

I acknowledge that any assistance or statements made by the Province or its agents and employees about certain services or service providers are not representations or warranties of any kind. If I, the service provider or its agents, employees or contractors, suffer any losses, claims, damages, actions, causes of actions, costs or expenses that arise directly or indirectly from any act or omission of me, the service provider or its agents, employees or contractors, relating directly or indirectly to my application or the services provided to me under the SAJE Mental Health and Counselling Benefit, I agree to be responsible for these and acknowledge and agree that the Province and its employees and agents will not be liable.

Applicant's Signature

Missing or incorrect value

Date Signed

Missing or incorrect value

This consent is effective from the date of signature until either the described services and service provider have been assessed and deemed ineligible, or an approved service provider has been paid in full, as applicable.

I authorize a director or worker of the Ministry of Children and Family Development to disclose the information I have provided in this form to the service provider in Section 3 for the purposes of confirming the contents of this application and for billing and payment for the described services.

I acknowledge that if the described services and service provider are approved, payment for the described services will be paid directly to the approved service provider on my behalf, upon the service provider issuing an invoice to MCFD, and that I will not receive funds to pay for the described services or be reimbursed if I pay for the described services.

Applicant's Signature

Missing or incorrect value

Date Signed

Missing or incorrect value

When all required fields have been completed, the email button below will be enabled. A copy of this request form will be emailed to the SAJE program and you will also receive a copy.

If we have questions, we may contact you.

Applications are reviewed in the order they are received. You will be contacted by email when your request has been processed.

CF4147 (2023/11/08)

Ministry of Children and Family Development

PO Box 9784 Station Provincial Government

Victoria, BC V8W 9S5

78754acec68530a5f468c669a0d7632bcf71801e

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Confirmation

Request for SAJE Mental Health and Counselling Benefits

Instructions

Information Collection, Use or Disclosure

Section 1: Applicant Information

Applicant Mailing Address

Section 2: Mental Health and Wellness Services

Section 3: Service Provider Information

Service Provider Mailing Address

Section 4: Applicant's Responsibilities

Section 5: Consent to the Disclosure of the Information

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