Application for Scholarship

Please complete the application below to considered for scholarship funds from the Powerful Project. Scholarships are available to supplement the costs of therapeutic and clinical services. Please contact Lauren Foster at lauren@powerfulproject.org with any questions or concerns.

Client Name

First Name

Last Name

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Caregiver 1 (primary contact if under 18)

Name

First Name

Last Name

Phone

(###)

###

####

Caregiver 2 (if under 18)

Please complete if applicable.

Name

First Name

Last Name

Phone

(###)

###

####

Background Information

Please list all household members (name, date of birth, age, and relationship to client)

Reason(s) for Request

Please indicate the areas of clinical or therapeutic services where assistance is requested.

Mental Health

Developmental Delay

Trauma

Genetic Disorder

Neurodiversity

Other (please share in the section below)

Supporting Information

Please describe current treatment needs in detail, sharing diagnoses, previous treatments, and all pertinent information to help us help connect you with the resources needed.

Health Insurance Provider (please state if do not have)

Reimbursement Rates

I have checked with my insurance provider to find out what “out of network” reimbursement rates are.

Per Session Contribution

Amount I can afford to pay per weekly session

Monthly Contribution

Amount I can afford to pay per month for services

Application Terms

Please check the following to indicate your agreement and understanding.

I have signed a HIPAA FORM and a CONSENT TO TREAT form for Telehealth.

I understand that The Powerful Project, Inc. (non-profit EIN 82-457-7593) will do it’s best to connect me / my family / my child with requested therapeutic services once my application is approved.

Donations and scholarship amounts provided are dependent upon donations received by the Powerful Project.

Signature

By typing your name in the box below, you are effectively providing your signature, indicating the above information is accurate. Upon review, a Powerful Project representative will contact you to schedule an Intake Session with a member of our Board of Directors. Approved applicants will be required to: • Complete required forms and paperwork. • Agree to a 48-hour notification for cancellation or rescheduling of appointments with our Therapeutic Resource Partners.

Any other additional info you'd like to share: