OATH Therapy Scholarship Application
Sign in to Google to save your progress. Learn more
Section 1: Contact & Demographic Information
Client Full Name  *

Client Date of Birth: 


 *
Parent/Guardian Name(s): If applicable 

Parent/Guardian DOB: 

Phone Number  *
Email Address *
Address *
Section 2: Family & Household Information
Marital Status: (Client or Guardian) *
Housing Situation *
Do you have any of the following?  *
Required
Other dependents/children: *
Section 3: Employment & Financial Information
Employment Status (Client or Guardian):  *

If unemployed:

Date of last employment: [Date]

Date expected to return to work: [Date]

Current Employer: 

Previous Employer: 

Job Title(s): 

Section 4: Clinical Information & Treatment History
Untitled Title

What are you seeking therapy for? 

 *
Required
Describe any OCD or Anxiety-related symptoms you're experiencing:
 *
Mood-related concerns:
 *
Have you ever experienced suicidal ideation, self-harm, or suicide attempts?

If yes, please describe and provide date of last occurrence:

 *
Substance use concerns (past or present):
 *
Section 5: Previous Mental Health Treatment

List all past/current mental health providers (including IOPs/hospitals):

Name

Approximate Month/Year of Services

Approximate Number of Sessions

 *
Describe your experience with previous providers. What helped? Why did you stop?
 *
Section 6: Readiness & Motivation

Are you able to commit to weekly therapy sessions (in-person or virtual)?

 *

Do you have access to a private space for virtual sessions (if applicable)?

 *

Motivation level to begin treatment (Scale 1–5)

1 = Not motivated at all

5 = Very motivated

 *

What do you hope to gain from therapy? Why do you think treatment would benefit you?

 *
Section 7: Financial Assistance Request

Are you able to pay something toward your sessions?

 *
Please explain your financial hardship or circumstances that make scholarship support necessary:
 *
Section 8: Certification & Signature

I certify that the information provided above is accurate and true to the best of my knowledge.

Full Name (Typed Signature): 

Date: 

 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of OATH Therapy.

Does this form look suspicious? Report

Google Forms