Mental Health Therapy Funding Application Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number
Address
Therapy Details
Therapist/Provider Name
Type of Therapy
Individual
Group
Family
Other
What are your therapy goals?
Number of Sessions Requested
Estimated Total Cost
Funding Need
Please describe your financial need for funding
Are you receiving other funding/support?
No
Yes
Amount of Funding Requested
Additional Information
Anything else you'd like to share?