Application

Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Sex

FemaleMaleTransgenderNon-binary / non-conformingPrefer not to respond
Race / Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhitePrefer not to respond
I have health Insurance

YesNo
If yes, who is your insurance provider?
Occupation
If unemployed, last job and dates worked
This grant is for

MyselfOther
If other, please write their name below
Relationship to Applicant

ChildSiblingParentOther
I already have a therapist

YesNo
If yes, what is the name and email of your therapist?
How many therapy sessions do you wish to receive? (Maximum 10 over the course of 1 year)
If there is any other information you wish for us to know, please provide it in the space below
Please provide a copy of your photo id

Cancelof
Please provide a copy of your latest tax return *** You MUST blackout your SSN in order to be approved.

Cancelof
Please note that although we would love to help all applicants, unfortunantely, we cannot accept all applications. We will inform you on the status of your application via email within one week of submission. Thank you.
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