Group Scholarship Application

Caring Connection believes in accessible therapy services for all. Please complete the form below to apply for scholarship funds for the September 8th- October 13th pregnancy and postpartum support groups.

Name

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Please briefly describe what challenges are prompting you to seek care:

I affirm that I have a financial hardship that prevents me from accessing mental health services at this time.

To affirm this statement please type your full name below.

CCC wants to partner with people to make care accessible. What session amount can you contribute, whether it's $10, $20, or more toward your mental health services please describe that below.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Caring Connection Counseling harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes