Grant Program Application

To be considered for a grant through Midwest Brainspotting Institute (MBI) Grant Program, clinicians providing Brainspotting (BSP) treatment must meet the following criteria:

1. Be a current MBI member.

2. Be fully licensed to practice psychotherapy in their state according to their individual discipline (e.g., psychology, medicine, social work, etc.).

3. Have physically or virtually attended and completed at least Phase 1 and Phase 2 Brainspotting live(not DVD) trainings (with dates attended):

4. Have acquired at least six months of BSP experience.

5. Agree to seek supervision with a BSP consultant as needed.

6. Agree to abide by the ethical codes of conduct as outlined by their profession and state/province of practice and international Brainspotting organization.

7. Agree to use grants only for rendering BSP therapy directly to a client/recipient.

8. Must work in private practice or for an organization that accepts single-case agreements.

9. Must coordinate or secure the single-case agreement with organization prior to submitting application to the MBI Grant Committee.

10. Include in application Release of Information form signed by client to share client information related to the MBI Grant Program application.

11. Submit completed MBI Grant Invoice form, Therapist Summary of Treatment, Client Initial Screening and Satisfaction Survey, and other applicable billing statements to MBI Grant Committee when sessions have been completed (not more than 10 sessions).

12. Have read, understood, and agree to follow all MBI Grant Program guidelines and submit all completed Grant Program documents.

 

I, {name}, hereby verify that I meet all of the above requirements to provide services through the MBI grant program and agree to be subject to verification on all items herein. In no event shall MBI be liable to clients, participating therapists, or anyone else as a result of this program.

This information is confidential and will be used for the sole purpose of tracking demographic information about the people we serve through this program. MBI does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, or sexual orientation, in any of its activities or operations. In no event shall MBI be liable to clients, participating therapists, or anyone else as a result of this program.

Please, indicate below which of the following criteria apply to you (check all that apply):

 

Household Size	Annual Income	Federal Poverty Guideline (FPG)
1	$12,060	$15,075
2	$16,240	$20,300
3	$20,420	$25,525
4	$24,600	$30,750

*For current guidelines: https://www.projusticemn.org/fedpovertyguidelines/

I hereby agree that all information indicated in this document is true to the best of my knowledge and my signature indicates my agreement with receiving Brainspotting services through this Grant Program. I also agree that I am legally able to give consent for treatment for these services. In no event shall MBI be liable to clients, participating therapists, or anyone else as a result of this program. In no event shall MBI be liable to clients, participating therapists, or anyone else as a result of this program.