HOW IT WORKS
FOR CLIENTS
FOR PRACTITIONERS
FOR STUDENTS
CLIENT/PRACTITIONER ASSISTANCE REQUEST FORM
STUDENT/INSTRUCTOR SCHOLARSHIP
APPLICATION FORM
BENEFICIARY
FEEDBACK FORM
CLIENT / PRACTITIONER GRANT REQUEST FORM
Client Information:
(this section may be left blank if the client prefers to remain anonymous)
Name
Address
City
State
Zip Code
Primary Phone
E-Mail Address
Practitioner Information:
(to be completed by client or practitioner)
Name of Practitioner
Name of Organization
Address
City
State
Zip Code
Primary Phone
E-Mail Address
Web Address
Healing Modality
Dates of Treatment
Cost of Treatment
Health Insurance Coverage
Grant Amount Requested
(Optional) Client’s Reason(s)
for Seeking This Treatment
or Counseling
Note: Approved grant payments are made on behalf of the client in the form of a check made out and mailed to the Practitioner or Counselor.
