Scholarship Application

Scholarship Application
Healing Grace can offer limited scholarships to help offset your cost for treatment if you are paying out of pocket and not using insurance. To see what you might qualify for please complete the following questionnaire which will be submitted to the Director of the practice for review. All information will remain confidential.
Contact Information
Are you renewing a scholarship?*

YesNo
Contact Name*
Contact Phone*
Contact Email*
Client Name
if different from contact above
Date of Birth
of the person needing services
Do you have insurance you could use?*

YesNo
Select what insurance you have*

BCBSTriCareOptum/GEHAUHC/UBHMedicareMediCaidHumanaAetnaCignaAmBetterOther
Please explain why you don't want to use insurance for therapy.*
Why should you get a reduced rate? (Please provide a short paragraph) *
Are you willing to see a Provisionally Licensed Provider or an Intern to receive a lower rate?*

YesNo
You will be offered a PLPC or intern if not already established with someone. If not interested in this option, you will be subject to a higher rate.
I understand that I have to pay at the time of the session as a condition of this form. Failure of payment can result in impairment of care. My signature below indicates comprehension of this form. *

Clear
Scholarships can potentially reduce cost to $60 per session for interns or $100 per session for PLPCs.

Scholarships are awarded in 6-month increments. If you need ongoing assistance beyond 6 months you will need to reapply at that time.

Please Note: You will receive an acknowledgment email from us (typically within 48 hours) with the Directors approved session amount. You must electronically sign (by replying "I agree") that acknowledgment before we can proceed with therapy sessions at a reduced rate. Please keep an eye out for this email.
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