Therapy Scholarship Application
Complete all applicable fields from the client intake PDF. Fields are optional unless marked required in the original. Preserve labels and structure as closely as possible.
Client Information
I am completing this form for
*
Myself
My minor child or child in my legal care
Dependent adult in my care
Client first name
*
Client last name
*
Preferred name or nickname
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Biological sex
*
Primary phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Primary address street
*
City
*
State and ZIP code
*
Preferred contact method
*
Phone call
Text message
Email
No preference
Best time to reach you
*
Preferred language
Guardian Information and Contact Restrictions
Guardian First Name
*
Guardian Last Name
*
Relationship to Client
*
Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email
example@example.com
Custody arrangements, court orders, or legal restrictions affecting who may be contacted?
*
Yes
No
If yes, please describe
Emergency Contact
Emergency Contact Name
*
Relationship to Client
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Concerns and Prior Services
What is bringing the client/child to seek support at this time?
*
Which concerns apply?
*
Anxiety, worry, or panic
Depression or low mood
Trauma or PTSD
Grief or loss
Anger or emotional dysregulation
Relationship or family conflict
Behavioral concerns
School or work stress
Substance use concerns
Self-esteem or confidence concerns
Other
Has the client previously received counseling or mental health services?
*
Yes
No
If yes, please describe the provider type, duration, and any helpful context.
Household and Financial Information
Number of People in Household
*
Ages of Children in Household
Household Type
*
Single adult
Couple without children
Single-parent household
Two-parent household
Multi-generational household
Other
Approximate Total Gross Annual Household Income
*
Under $15,000
$15,000 - $24,999
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $64,999
$65,000 - $74,999
$75,000 - $99,999
$100,000 or more
Amount Household Can Afford per Counseling Session
*
$0 - cannot contribute at this time
$1 - $25 per session
$26 - $50 per session
$51 - $75 per session
$76 - $100 per session
More than $100 per session
Insurance and Service Preferences
Do you currently have health insurance?
*
Yes
No
Currently enrolling
Insurance provider
Member ID or policy number
Does your insurance cover mental or behavioral health services?
*
Yes - fully covered
Yes - with copay or deductible
No - not covered
I am not sure
What type of services are you seeking?
Individual therapy - adult
Individual therapy - child or adolescent
Couples or marriage counseling
Family therapy
Group counseling
Other
Preferred session format
*
In-person
Telehealth or video
No preference
Preferred session frequency
Weekly
Biweekly
Monthly
Not sure
Benefits, Referral, and Faith Preferences
Government Assistance and Benefits
Medicaid or AHCCCS (Arizona)
CHIP (Children's Health Insurance Program)
SNAP (food assistance)
WIC
SSI (Supplemental Security Income)
Other
How did you hear about us?
Referred by my therapist or counselor
Referred by a school or educator
Referred by a doctor or physician
Referred by a church or pastor
Referred by a case manager or social worker
Other
Referral Source Name
Current Faith Background
Christian or Protestant
Catholic
Non-denominational Christian
Other faith tradition
No religious affiliation
Other
Counseling Preferences
Prayer, when appropriate
Biblical principles
Scripture
Christian perspective if requested
I prefer a secular counseling approach
Other
Additional Information, Access Needs, or Requests
Client Acknowledgment
Printed Name
*
Relationship to Client
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internal Administration
Internal-only notes for reviewer
Review date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Administrative eligibility and verification checklist
*
Application is complete
Insurance information reviewed
Presenting need aligns with the charitable program
Qualified therapist options identified
Household and financial information reviewed
Other
Application decision
*
Approved
Conditionally approved
Waitlisted
Declined
Scholarship level or amount approved
Approved client contribution
Scholarship start date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scholarship end or review date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Selected or matched therapist
Therapist practice
Number of sessions authorized
Authorization period
Payment or reimbursement method
Renewal review date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internal review notes, conditions, and follow-up
Final approval or committee chair
Approval date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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