Therapist Scholarship Participation Application Form

Therapist Scholarship Participation Application Form

Please complete this application to apply to participate as a therapist in our scholarship program. The program is free, however there is a small application fee to support our administrative costs.
Name

First NameLast Name
Business Name (if applicable)
Email

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Why do you want to participate as a therapist in the Lit Path scholarship program?
What state(s) are you licensed to practice in?
To select multiple states, hold down the 'Ctrl' key while selecting
License Number(s)
What is your customary fee per session?
What is your cancellation policy?
What draws you to clients struggling with addictions and/or partner trauma?
Describe your experience (including years and modality) with clients struggling with addictions and/or partner trauma?
What is your relapse prevention program/strategy?
At what point in your clients struggle with addiction and/or partner trauma do you refer them to a higher level of care?
What biases about addicts and/or their partners might get in your way?
How do you separate your personal beliefs and biases when they are different from your clients?
Do you have a therapist you see regularly?
How much therapy have you had yourself?
What is your personal experience with recovery and healing?
What do you specialize in?

Other
What addiction(s) and/or trauma do you consider yourself to specialize in?

Other
What training/certifications have you completed for your specialty (such as CAP, CSAT, CGAC, CEDS, CCPS, etc)? What institution provided the training/certification?
What about your therapy strategy makes you stand out from other therapists?
What do you think makes you successful in helping others recover from addiction and/or heal from betrayal trauma?
Were you referred by a participating therapist?
Who was the participating therapist?
Use following Promo Code: REFERRAL10 to claim 10% off
Application Processing Fee

We are a 501(c)(3) and application fees allow us to focus our donations on our scholarships and enable us to provide our scholarship service for FREE to awesome therapists like YOU!

Application Processing

Participating Therapist Application Fee

Processing of application

$39.99

Credit card processing fee 3%

Thank you for helping us cover the cost!

$1.20

Optional: Add a Donation to the Lit Path Scholarship Fund!

Your donation helps provide therapy scholarships for individuals and couples seeking healing from CSBD and betrayal trauma. Every contribution makes a difference — thank you for helping others find hope and recovery.

$1.00 Donation Amount

Enter coupon

Total

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Credit Card Number	Security Code
Expiration Month	Expiration Year

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Therapist Scholarship Participation Application Form

Application Processing Fee

Application Processing*

Application Processing