Branded Scholarship Application Form

Branded Scholarship Application Form

Please complete this application to apply to participate in our branded scholarship program.
We are thrilled to offer these programs to help individuals access the amazing healing treatment you offer. Please note the following about this application form:
- The benefits of the branded scholarship program are available in this document. It is an amazing program!
- You must already be a participating therapist in our scholarship program before you can apply for your organization to participate in the branded program. You may apply here as a participating therapist.
Name

First NameLast Name
Business Name (if applicable)
Email

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Why do you want to include your intensive program in the Lit Path scholarship program?
What state(s) are you licensed to practice in?
To select multiple states, hold down the 'Ctrl' key while selecting
What is your customary fee per intensive?
If clinicians from multiple practices are involved, which organization will receive payment for the intensive services?
What is the cancellation policy for your intensive?
Describe your experience (including years and modality) with leading intensive treatment programs for clients struggling with addictions and/or partner trauma?
What is the name of the intensive program you would like to include?
Where do the intensives typically take place?
Please describe the environment the intensive takes place in
On average, how many participants attend each intensive?
What is the primary treatment focus of the intensive?

Other

Team Composition: Please provide the names and roles of all individuals who lead or offer clinical support in your organization. Please enter the name of the individual under their role (please DO NOT enter more than 1 role per name line).

Rows	Licensed Therapist	Registered Intern	Certified Coach	Other (include role in response)
Name 1
Name 2
Name 3
Name 4
Name 5
Name 6
Name 7

If more than 7 clinicians above, please list the remainder below:
Please enter the number of days or weeks the intensive take place over. Example: The intensive takes place over 2 weeks

The intensive takes place over # of* days or weeks*.
Please provide a short overview or description of your organization.
Please provide a clinical outline of the intensive program.

Cancelof
Please provide marketing material(s) for your organization.

Cancelof
What are the circumstances under which an individual would be denied acceptance to the intensive?
What are the circumstances under which an individual would be removed from the intensive after it started, but before it finished?
At what point in your clients struggle with addiction and/or partner trauma do you refer them to a higher level of care?
What about your intensive program makes it stand out from other programs?
What do you think makes your intensive successful in helping others recover from addiction and/or heal from betrayal trauma?
Branding Information
Please provide the informaiton below for us to create your branded donation page.
Please provide your logo for the branded page

Cancelof
Application Processing Fee
We are a 501(c)(3) and application & program fees allow us to focus our donations on our scholarships so more individuals can get access to treatment.

If your application is approved, we will deduct this application cost from the 1st year's annual program fee. The annual fee for intensive participation is $499 and includes your own branded scholarship program for services with your organization. This will be invoiced after program acceptance.

The application fee of $89.99 will not be refunded if your organization is not accepted in our program.

Application Processing

Branded Scholarship Initial Annual Fee and Application Fee

Future years' annual fees of $499 will be invoiced each year.

$499.99 Quantity

Optional: Add a Donation to the Lit Path Scholarship Fund!

Your donation helps provide therapy scholarships for individuals and couples seeking healing from CSBD and betrayal trauma. Every contribution makes a difference — thank you for helping others find hope and recovery.

$1.00 Quantity
Item subtotal:

Credit card processing fee 3%

Thank you for helping us cover the cost!

$15.00 Quantity

Enter coupon

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

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Branded Scholarship Application Form

Branding Information

Application Processing Fee

Application Processing*

Application Processing