Single Person for New Therapy

Applying as a Single Person Continuing Therapy? *

Yes

No

Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have financial need? *

Yes

No

Will you commit to weekly group therapy sessions and pay for your portion of the cost? *

Yes

No

Will you commit to individual therapy 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 Circles of Grace of Murray, UT solely to coordinate payments for therapy received. *

Yes

No

*

By checking, I accept and commit to participating in the Lifestar program to the best of my ability. The attendance requirements of our scholarship recipients are 85% attendance rate. That is 2 missed sessions in a 3 month period. Medical or family emergencies will be considered on an individual basis, in which case we will need to be notified. This is required and failure to fulfill these requirements will disrupt your eligibility to receive funds and the scholarship will be revoked.