Therapy Grant Contact Us - Alisa Ann Ruch Burn Foundation

Personal information

First Name

Last Name

Email

Phone

Address

Street

City

State

Zipcode

Tell us more about you

Participant type

To which gender do you most identify

Date of Birth

Do you have insurance?

Yes
No

Will your insurance pay a portion of the charges?

Yes
No
Don't know

which insurance six

Have you ever seen a therapist or counselor before?

Yes
No

Are you able to commit to seeing a therapist regularly for a minimum of six months?

Yes
No

Please describe any topics or goals you would like to address within counseling

Do you have a therapist that you would like to work with?

Yes
No

If no, do you have any preferences in a therapist? (example: gender, location, etc.)

Which grant are you applying for?

Tier 1 (First time applying): $1800 grant. Max $300/month
Tier 2 (Reapplying): $900 grant. Max $150/month

Statement
I understand that, if awarded a therapy scholarship, AARBF will pay my therapist directly until the dedicated funds have been disbursed. While AARBF will send me and my therapist reminders and updates, I will be responsible to cover the costs of any services that go above and beyond the therapy scholarship award that I receive. If I am unsure of how much of my scholarship remains, it is my responsibility to contact AARBF to find out. If I fail to attend therapy for two months, I understand that the funds will be reallocated to someone on the waitlist.

Yes, I understand and agree to the terms outlines above in the participant agreement
No, I do not agree to abide to the participant agreement