3 Treasures Grant Application

Three Treasures Institute

GROWING RESILIENCE THROUGH NOURISHING PEOPLE & PLACE
GRANT APPLICATION

In order to increase access to holistic healthcare, we offer a limited number of discounted consultations for Integrative Chinese & Functional Medicine with one of our member practitioners. If you are interested in applying, please fill out the form below. Thank you.
Name of Applicant / Patient

First NameLast Name
If Applicant / Patient is a minor, please fill out your name as the parent or legal guardian:

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country of residence
Age of applicant / patient
Annual Household Income
Information about applicant
Number of Children in the Home
Please select if you are one of the following populations:
I identify my ethnicity as (select all that apply)
If you checked "other" in the question above, please fill in your identified ethnicity here:
Income Guidelines

Poverty and low income can be measured in various ways. Due to California’s high cost of living, 200% of the federal poverty level (FPL) is a more realistic measure of financial hardship than the official 100% FPL. [https://www.cdph.ca.gov/Programs/OHE/CDPH%20Document%20Library/HRSU/HCI%20One%20Page%20Poverty%20Fact%20Sheet%20June%202019%20LM.pdf]
Our standard discount is 50% of the usual fee of our member practitioners. Is this a reasonable amount for you? (Check standard rates on individual practitioner websites)
If 50% is not enough of a discount for your financial situation, please state the amount you feel you are able to pay and give a short description of your current circumstances.
Is there anything else you would like us to know?
Do you have a preference of which practitioner you will be working with?
Please complete the following section. PLEASE NOTE: ALL BOXES MUST BE CHECKED AND APPLICATION MUST BE SIGNED FOR THE APPLICATION TO BE PROCESSED:
Please check the appropriate box:
Signature
Please verify that you are human
Thank you.

We will review your application and be in touch soon.
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Three Treasures Institute

GRANT APPLICATION

Income Guidelines

Thank you.