Financial Assistance Form

If you’re experiencing financial hardship, you may be eligible for assistance. We believe wholeness should be accessible to all and that financial barriers should never stand in the way of healing and growth.

We offer a limited number of hardship-based scholarships. Depending on your specific situation, these scholarships may cover the full cost of your sessions or significantly reduce your service fees to ensure our care remains accessible to you.

Your Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What type of services are you interested in receiving at Temple Wellness?

What is your reason for seeking Healing, Freedom, and/or Counseling? What is your "Why"?

What factors have contributed to your current financial hardship?

Sessions are typically scheduled once or twice per month. Please let us know if you can contribute a partial payment toward your session(s) and the specific amount you are able to pay per session?

Thank you for applying for financial assistance. We will get back to you as soon as possible.