Scholarship Application - Grace Counseling

Grace Counseling is NOT currently accepting applications for the Scholarship Fund.

Explore the other ways that Grace Counseling offers Reduced Fee Services.

Grace Counseling’s Scholarship Board welcomes your request for financial aid. As part of your request, please note:

None of your information will be shared outside of the Scholarship Board.
If you are approved for assistance, you will be expected to adhere to Grace Counseling’s appointment, attendance and payment policies.
If you are approved for assistance, the assistance will be valid for a limited time and number of sessions, which will be communicated to you with your approval.
If you go longer than 60 days without using your approved scholarship sessions, it will be canceled and you will have to reapply.
The Scholarship Board will not evaluate your need for counseling. The Board is only determining if funds will be used to subsidize your expenses.

Scholarship Application

Name

First

Last

Email

Phone

Birth Date

Are any other household family members currently in counseling:

Employer & Payrate/Salary:

Other Income Source:

Cost of Housing:

Monthly Debt Payments:

What is the max out of pocket fee that you can afford per session:

Do You Have Medicaid:

Special Circumstances the Committee Should Know About

My Current Grace Counseling Therapist (if you have one):

By checking these boxes, I understand that my therapist will release the following information to the scholarship team to help assist their decision about financial aid:

Number of sessions client needs

Rate suggestions

Clinical factors relevant to financial needs

Please bring in proof of your household income to your next session: copies of current pay statements; Current W-2 or 1099 Forms, or your most current Tax Return. By submitting this form, you are acknowledging that the information is accurate.