The Bell Jar Collective: Therapy Scholarship Application

Full Name

First NameLast Name

Preferred Name (if different):

Age

Birthdate

MonthDayYear

Are you under 18? Applicants under 18 must have a parent or legal guardian involved in therapy services.

Email

Where the confirmation will be send to

Mobile No

Format: (000) 000-0000.

City & State:

Preferred Method of Contact:

Briefly describe your current support needs (no graphic details required).

What type of therapist or support are you looking for?

Are you requesting full or partial coverage?

How much can you contribute per session? $

By signing below, you certify that the information provided is accurate and that you are the individual completing this application. You acknowledge that The Bell Jar Collective provides limited financial assistance only and that submission of this application does not guarantee funding.

Upon submission, you will receive an email confirmation that your application has been received. Please retain this confirmation for your records.

Signature

The Bell Jar Collective: Therapy Scholarship Application

Applicant Information

Mental Health Support Needs

Funding Request