Scholarship Request Form
Due to the generosity of Seacoast Church, a scholarship may be available to ensure that finances are not a barrier to care. To apply for a scholarship, please complete the following application. All scholarships will be reviewed to determine how much financial assistance can be provided toward the standard hourly rate. A complete application, along with supporting documentation, must be submitted before a request can be reviewed. Please allow 7 business days for review. For your protection, all information is confidential. Scholarships are approved for 3 month terms and may be renewed with re-application.
Name
*
First Name
Last Name
Email
example@example.com
Please describe briefly why you are requesting financial assistance for counseling.
*
Do you attend a local church?
*
Yes
No
If yes, which church?
*
Tell us about your employment status.
*
Employed Full-Time
Employed Part-Time
Retired
Unemployed
Where do you work?
*
What is your estimated monthly income?
*
What are your estimated monthly expenses?
*
Please attach one of the following: current pay stub with YTD income; or your last 2 months of bank statements (full bank statements, not screenshots).
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