Financial Hardship Application
Name
*
First Name
Last Name
date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Therapist's name:
*
Reason for Financial Hardship Scholarship Request
Please Select
Loss of income
Excessive medical debt
Short term disability
Debt to income ratio
Low income / High expenses
Other (explain below)
Please explain your request:
*
Requested duration of scholarship:
*
What is your household annual income:
*
Who does the income above cover?
*
Who is your insurance carrier?
*
Do you have deductibles/copays? Explain
*
Based on the above chart, I qualify for a session rate of: Please note: our scholarships can cover up to half of the cost of therapy sessions. (this does not necessarily mean this is what you will pay):
*
75-150
Please provide proof of income (tax return, pay stub, etc):
*
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