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Orchard Human Services, Inc.
Scholarship Application - Courtesy of PNE Institute, LLC
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1
Scholarship Application - 2021
I wish to apply for a scholarship from PNE Institute, LLC to cover unpaid balances for counseling, intervention, educational, and mental health services rendered through Orchard Human Services, Inc., including services rendered by Dr. Darleen Claire Wodzenski, LPC, NCC. I understand that scholarships only apply to unpaid balances after client, insurance, and third party payer payments have been applied.
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2
Your Name
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First Name
Last Name
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3
Name of Your Partner/Spouse
If Individual Is Also Requesting Scholarship
First Name
Last Name
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4
First Child or Family Member
First Child For Whom You Are Requesting Scholarship
First Name
Last Name
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5
Second Child or Family Member
Second Child For Whom You Are Requesting Scholarship
First Name
Last Name
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6
Additional Children or Family Members
Additional Family Members For Whom You Are Requesting Scholarship
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7
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Antigua and Barbuda
Argentina
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Aruba
Australia
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
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Canada
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Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Japan
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Kenya
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Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
Phone Number
*
This field is required.
If We Have Questions, What Number Would You Like Us To Call?
Area Code
Phone Number
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9
I am formally requesting a scholarship from Psychoneuroeducational Institute, LLC for unpaid balances rendered by Orchard Human Services, Inc. and/or Dr. Darleen Claire Wodzenski, LPC, NCC for the individuals indicated above.
*
This field is required.
I am requesting the scholarship for the following reason[s].
Financial Strain or Hardship
Excessive Medical and Mental Health Bills
Loss of Income Due To Unforeseen Circumstances
Developmental, Medical, or Mental Health Frailty of Family Member
Other [please complete next item]
Please Select
Financial Strain or Hardship
Excessive Medical and Mental Health Bills
Loss of Income Due To Unforeseen Circumstances
Developmental, Medical, or Mental Health Frailty of Family Member
Other [please complete next item]
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10
If You Selected Other Above
Please briefly describe the reason for your request for scholarship.
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11
Are You Requesting A Total, Partial, Or Supplementary Scholarship
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Please select all that apply
Partial Scholarship [Complete Next Box]
Temporary Scholarship Until Insurance or Health Care Benefits Are In Place To Cover Services
Supplementary Scholarship To Cover Balances Not Paid By Insurance or Health Care Plan
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12
If You Are Requesting A Partial Scholarship Please Indicate The Dollar Amount You Are Able To Contribute Per Appointment
*
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13
If You Are Requesting A Partial Scholarship
Please complete ONE of the following.
Please indicate the dollar amount of scholarship you are requesting.
I am able to make the above single payment [type amount of single payment in box above]; requesting scholarship for rest.
I am able to make monthly payments in this amount; please provide scholarship for rest.
I will make partial payment toward each date of service; please provide scholarship for rest.
Please call me at the above PHONE NUMBER to discuss my request for a scholarship.
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14
Upload
Drag and Drop Files Here To Support Your Request For Scholarship, such as medical or financial documents or letter of explanation.
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15
Signature
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Clear
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16
Type Name From Signature Line
*
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First Name
Last Name
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17
Date
*
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-
Date
Year
Month
Day
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18
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