Grant Application
Please complete in full to be considered for the grant. Keep in mind, if approved, the maximum amount of sessions covered is between 8-10. If there are 2 no shows reported, funding will automatically be discontinued. There will need to be a release of information on file with your mental health provider to share billing account and appointment scheduling information with Bloom Mental Health Foundation. ***Interns will need to apply per semester and funds will be awarded according to availability.
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Which grant funding are you applying for?
Intern
Therapy
Please give a short description of your need and how this grant will benefit you.
Provider/Resident Supervisor Section
Please have your Mental Health Provider or Resident Supervisor complete this section
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you recommend this client/resident for this grant and why?
Provider Section(Please have your mental health provider complete this section): Has your client signed a ROI for you to communicate with Bloom Mental Health Foundation for billing and scheduling purposes?
Yes
No
Client or Resident Signature
Provider or Resident Supervisor Signature
Submit
Submit
Should be Empty: