Corey Holmgren | Therapy Scholarships

Today's Date*

Self

Name*

First Last

Phone Number*

Email*

Birthday*

Address*

Street Address Address Line 2 City State ZIP Code

Spouse

Name*

First Last

Phone Number*

Email*

Birthday*

Address*

Street Address Address Line 2 City State ZIP Code

Do you have financial need?*

Yes
No

Are you married?*

Yes
No

Will you commit to every Thursday from 6:00 pm to 9:00 pm at 151 E 5600 S, Murray, UT 84107?*

Yes
No

Will you commit to 12 months of weekly group therapy sessions and pay for 50% of the cost (no more than $250/month)?*

Yes
No

Will you commit to 3 individual therapy sessions for self and spouse (6 total), as well as 3 couple sessions as scheduled with your therapist?*

Yes
No

I give The Corey Holmgren Memorial Fund permission to discuss billing and attendance (NOT therapy or anything related to the actual therapeutic process) with Lifestar of Salt Lake solely to coordinate payments for therapy received.*

Yes
No

Tell us about you as a couple. (Please be as specific as you feel comfortable)*

Tell us about your financial situation and how you could benefit from this scholarship. (Please be as specific as you feel comfortable)*

Please upload .jpg or .pdf of taxes (form 1040) showing Adjusted Gross Income (AGI).*

*

By checking, I accept and commit to participating in the Lifestar program to the best of my ability. Failure to fulfill this agreement may result in removal of scholarship funds.

Therapy Scholarships

Scholarships: Eligibility & Applications

All applicants must:

Self

Spouse