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.
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

Single ParentMinor Child (under 18)Senior Citizen (over 65)Disabledn/a
Number of Children in the Home

12345+n/a
Please select if you are one of the following populations:

Recent Immigrant (last 10 years)RefugeePrefer not to Answer
I identify my ethnicity as (select all that apply)

AsianBlack / AfricanCaucasianHispanic / LatinxNative American / IndigenousPacific IslanderPrefer not to answerOther (please fill in the blanks on the next question)
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)

YesNo
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?

Bess Donley (www.bessdonley.com)Jasmine Rose Oberste (www.drjasmine.co)No preference
Please complete the following section. PLEASE NOTE: ALL BOXES MUST BE CHECKED AND APPLICATION MUST BE SIGNED FOR THE APPLICATION TO BE PROCESSED:

The information presented in this application is true and complete to the best of my knowledge.I agree to and understand that while Three Treasures Institute is providing access to holistic and integrative healthcare through discounted treatments, I will not hold Three Treasures Institute responsible, nor will I take legal action under any circumstanceI give Three Treasures Institute permission to contact me using the contact information provided above
Please check the appropriate box:

I am the patient / applicant and I am 18 years or olderI am the parent or legal guardian of the patient / applicant
Signature

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Three Treasures Institute

GRANT APPLICATION

Income Guidelines

Thank you.