Financial Assistance for Therapy & Counseling

Financial Aid Application

We never want money to come in-between you and the help you are needing. Please complete all fields below in order to be considered for any scholarships or financial assistance for therapy we may have available, so that you or your family can best utilize our services.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Which of our services are you most interested in?(Required)

How many people from your household are planning to utilize our services?(Required)

Please enter a number from 1 to 10.

Enter the Amount of Your Total Household Annual Income(Required)

Enter the Amount of Your Total Monthly Expenses(Required)

List all of your assets(Required)

Enter combined total monetary amount of assets(Required)

List all your liabilities(Required)

Enter combined total monetary amount of liabilities(Required)

Why are you in financial need and what would it mean to you to receive financial aid from us?

Upload your most recent tax return

Max. file size: 50 MB.

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