APF Scholarship Application Treatment and Wellness Services

Access Psychology Foundation Scholarship Application

Treatment and Wellness Services
The Access Psychology Foundation (APF) partners with Cognitive & Behavioral Consultants, LLP (CBC) to provide treatment and wellness services in evidenced-based Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT), for all who need it, regardless of income. Evidence-based therapies are subject to rigorous research to confirm their treatment effectiveness.

APF allocates funding donated by dedicated supporters to significantly reduce the cost of care for eligible scholarship recipients. We use the information gathered from the application to be as fair as possible when awarding aid.

Each applicant is eligible to receive a scholarship that covers up to 90% of the costs.

APF will provide clients with access to counseling that fits their unique needs:
- Sessions can be structured for individuals, couples, or families
- Counseling is available in English and Spanish
- Therapy can be on a short- or long-term basis
- Counselors can see clients in-person at the CBC offices in White Plains, NY, Manhattan, NY or virtually through our online platform
- We’ll assign a therapist to match specific needs and preferences
Eligibility
- Applicants must be from a historically underrepresented group
- Present evidence of financial need
Application Components
- Completed APF Scholarship Application
- Financial Documents (including Prior Year Tax Return)
To apply for this APF scholarship, please complete the following application below in its entirety. Should you have any questions, contact an APF staff member at info@access-psychology.org or call (914) 810-0183.

Applicants will be notified of the status of their application within ten business days of submission, unless additional information is required.
I. Applicant Information:
Date of Application:

MonthDayYear
Full Name*

First NameLast Name
Date of Birth:

MonthDayYear
E-mail :*
Where the confirmation will be send to
Mobile or Preferred No. :*
Format: (000) 000-0000.
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemaleNon-BinaryOther
YesNoUndocumented Noncitizen
HispanicNon-HispanicNot Indicated
WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderOther
YesNo
If so, what country?
YesNo
If so, what country?
Place of employment (For students and parents completing this form on behalf of their children, please provide the name of the school) :*
If the patient is a minor, or still attending school, please indicate their student status.
YesNo
How did you learn about the Access Psychology Foundation scholarship?
If you learned about APF from a previous clinician, please include their name.
Yes, at Cognitive and Behavioral ConsultantsYes, at a practice other than Cognitive and Behavioral ConsultantsNo
If yes, what was the name of the clinical practice? If at CBC, who was your clinician?
YesNo
If yes, please indicate your insurance provider below:
II. Parent/Guardian 1 Information:

(For applicants under the age of 18)
Full Name

First NameLast Name
Date of Birth:

MonthDayYear
Place of employment:
Relationship to applicant:
E-mail :
Where the confirmation will be send to
Mobile No. :
Format: (000) 000-0000.
Home Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
III. Parent/Guardian 2 Information:

(For applicants under the age of 18)
Full Name

First NameLast Name
Date of Birth:

MonthDayYear
Place of employment:
Relationship to applicant:
E-mail :
Where the confirmation will be send to
Mobile No. :
Format: (000) 000-0000.
Home Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IV. Dependent Information

(If applicable)
Provide list any dependents under the age of 18, include names and birthdates:
V. Financial Information
This section is intended to help us get a better overall picture of your financial situation. Please include any information, including your annual household income, that will help us determine your level of support. This information can include, but is not limited to, a recent loss of job, divorce, major medical expenses, birth of child, college tuition, etc.

Please note that your prior year tax return is required.
Type here:*
Please upload documents to provide evidence of financial need. (Prior year tax return required.) *

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VI. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
Questions?

info@access-psychology.org

Access Psychology Foundation

One North Broadway, Suite 704

White Plains, NY 10607

(914) 810-0163

www.access-psychology.org
Should be Empty:

Access Psychology Foundation Scholarship Application

I. Applicant Information:

II. Parent/Guardian 1 Information:

III. Parent/Guardian 2 Information:

IV. Dependent Information

V. Financial Information

VI. Applicant's E-Signature