Financial Assistance Application

First Name *

Last Name *

Date of birth

Email *

Address

Street Address

Phone *

Who referred you to March on Mission? *

Where are you seeking mental health services?

Company Name *

Provider’s Name *

Company Address *

Company Phone Number *

Website *

Mental Health Services Requested *

Neurofeedback

Ketamine Infusions

EMDR

Talk Therapy

Others:

Note: Financial aid will only be awarded after you have been qualified by an approved vendor for approved services.

Eligibility

Please indicate your qualification(s) for this scholarship: *

Veteran

First Responder

Foster Child

If you are a veteran or first responder, please provide the name of your service branch or department: *

Mental Health Assessment

Have you previously been diagnosed with any mental health conditions? *

Yes

If yes, please specify:

Are you currently receiving any form of mental health treatment? *

Yes

If yes, please describe the treatment:

Please briefly describe the mental health challenges you are currently facing:

Treatment Commitment

The treatments we sponsor may require a commitment of 1-3 sessions per week. Are you able to commit to this schedule? *

Yes

Transportation and Accessibility

Do you have reliable transportation to attend your treatment sessions?

Yes

Financial Information

Please describe your current employment status and any financial challenges you are facing: *

I am not employed
I am employed part-time
I am employed full-time
I am a full-time student
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Financial challenges *

Please provide any additional information that you believe would support your application for this scholarship *

Signature

Clear

Date:

I certify that the information provided in this application is true and accurate to the best of my knowledge. I consent to March on Mission verifying any of the details provided in this application.

Please review all your responses carefully before submitting your application. We thank you for your courage in seeking support and look forward to assisting you.