Scholarship Application

Our practice reserves funding to provide scholarship stipends to clients that are financially unable to pay full service fees. To ensure that the clients who are most in need of financial assistance receive our scholarship stipend, we ask that you only complete this application if you are truly experiencing substantive economic hardship. In order to be considered, we require the this application to be completed in its entirety including proof of income (e.g., copies of pay stubs, bank statements, etc.).

I. APPLICANT INFORMATION/FINANCIAL GUARANTOR

Applicant's Name:

Address:

Telephone Number:

Email address

Date of Birth:

Do you have any mental health insurance coverage now?

Yes No

If yes, what is the name of your insurance company?

Have you consulted with a therapist before?

Yes No

If yes, when and with whom?

Was it helpful?

Is there a possibility my case might involve court proceedings?

Yes No

With what issue(s) would you like to get support?

What are your top 1-3 goals for therapy?

How many sessions do you expect to attend in total?

II. BUDGET

Please explain why you are requesting a reduced fee:

Prior to experiencing financial hardship, what would have been your typical budget for therapy (per session)?

What is your current budget for therapy (per session)?

For approximately how long do you expect to require a reduced rate for therapy?

III. FAMILY INFORMATION

APPLICANT:

Employer:

Hourly Wage:

EX: $15.00/hr

Hours Per Week:

Annual Salary:

Other Income:

SPOUSE:

Employer:

Hourly Wage:

EX: $15.00/hr

Hours Per Week:

Annual Salary:

Other Income:

IV. HOUSEHOLD MONTHLY INCOME

With what income does your family pay its expenses currently?

How much money is left over after you pay for essential expenses (food, rent/mortgage, utilities, etc)?