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North Austin Neurotherapy Scholarship Form
This form is to apply for reduced-priced IASIS Microcurrent Neurofeedback sessions from North Austin Neurotherapy. We understand that family finances are complex and a w9 doesn't tell the full story. Please be open and honest in your responses. A real-life caring, compassionate, and rational person is on the other end of this form. Someone will be in touch with you after this form is submitted. 
Name of person filling out this form:  *
Today's Date *
Email *
Phone number *
Name of person(s) applying for scholarship *
Tell me about your family's circumstances and why a scholarship would be beneficial to you at this time. 
What are you hoping to achieve through IASIS Microcurrent Neurofeedback (MCN) treatment at North Austin Neurotherapy?
Neurofeedback sessions are $125. We understand this is not within reach for some families. What price per session could you afford?  *
"When you learn, teach. When you get, give." 
--Maya Angelou

As a scholarship recipient, what do you plan to do to "pay it forward" to help others in your community? 
 *
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