CCC Financial Assistance Application

Caring Counselors Coalition Application

Financial Assistance Application
Contact Information
Title:*
Name*

First NameLast Name
Birth Date

MonthDayYear
Marital Status:*

SingleMarriedOther
E-mail*
example@example.com
Phone*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If "yes" what counselor would you like to see from the Caring Counselors Coalition?

Ashley BarberHerbert & Tanya Gooden (Couples)Cassidy DearShawndrika CookEssence Walker
Do you have access to any of the electronic equipment below?*

Tablet/IpadCellphoneLaptopComputerNone
Will you need a bilingual therapist? (If yes; please list below your primary language and secondary language) *
What is your present annual income?*
Do you have any dependents? If so, choose below how many dependents you have (not including yourself).*

12344+None
What is your occupation?*
Gross monthly income*
Other Income (Food Stamps Assistance, Government Assistance, etc)*
Monthly rent/mortgage*
Other Expenses Amount*
Why do you need counseling/therapy and what do you hope to attain by this assistance? Also, you can inform us of any other information you feel will help us with our decision. *
Please know that we will do everything we can to look over your application and see where we can offer assistance. An application is not a guarantee of our assistance; but we will do our best to offer help where we can. Assistance will be in the form of low cost counseling and/or financial assistance in receiving counseling with a Caring Counselor Coalition Counselor. CCC will give assistance for no more than up to 6 sessions per potential counselee. Please give us 7-10 business days to hear back from us for assistance. We will contact you via email or phone to let you know about next steps and our decision. Please keep in mind , if approved, we will have to attain more information (Birthday/ SSC Number, etc) for our records and a contract will be signed between you and Caring Counselors Coalition. Your information will be confidential and only shared between the Caring Counselor Board Members & Counselors. Please check below that you are aware of these stipulations.*

YES
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. **

YES
Signature
Should be Empty:

Caring Counselors Coalition Application

Contact Information