Payne Avenue Counseling

Prior to completing the following form, you may email Abigail Fobanjong at Abigail@groundingwaters.com to obtain a custom program ID number. If you would like to use your name, you're free to do that as well. A program ID will be assigned to you when this application is received.

Please enter your program ID or name:

Forms submitted without ID cannot be processed

The goal of the Payne Avenue Counseling program through Grounding Waters is to offer individuals access to a 12-session bundle of high quality counseling services. These counseling services are free to you. Anyone is able to apply for this program as many times as they would like. Preference will be given to new applicants and prior applicants who have used all 12 sessions within 6 months.

1. I am able to keep my appointment times. I understand that continuation in the program requires I have no more than 1 late-notice cancellation (less than 24-hour notice) or no-show.*

YesNoOther

2. I am invested in attending counseling. I am willing to attend 12 sessions within 6 months.*

YesNoOther

3. I agree to my information being kept in a secure database for future scholarship applications.*

YesNoOther

4. I live, work, go to church, or have family that lives in the Payne-Phalen neighborhood of Saint Paul. I am able to provide proof of this connection to the neighborhood.*

YesNoOther

Have you previously received counseling through Payne Ave Counseling Program?*

No, I have not received counseling through this scholarship.Yes; I completed the 12 counseling sessions within 6 months.Yes and I paused the counseling and did NOT complete the 12 sessions within 6 months.Yes and I forgot to attend some sessions and was not able to complete all 12 sessions within 6 months.Other

That’s it! Thanks for completing this application. We will be in touch with you soon. Please reach out to Abigail with any questions. Abigail@GroundingWaters.com or 651-246-6067