Counseling Scholarship Application

Thank you for applying for scholarship support through this application. Approved caregivers will either have their entire therapy sessions or their co-pays covered. Applications are reviewed at the end of every month, and applicants are contacted regarding their status by the 15th of the following month. Caregivers can use this scholarship to see one of our approved counseling providers.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

What is the best way to contact you?

Text

Do you currently have insurance?

Yes

If yes which provider do you have?

What is your co-pay?

Please explain your financial situation.(Required)

Please let us know what brings you in for counseling at this time.(Required)

Sliding Scale Contribution(Required)

Our full counseling session fee is $100. Please select the amount (if any) you feel you can contribute per session:

Care 4 the Caregivers

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