Application for Discounted Services through Pillars of Light in Love at the Empowering U Center
If you are in need of financial assistance for services via Pillars of Light and Love, a non-profit at the Empowering U Center located at 511 W Main St Suite 100, Trappe PA 19426, please fill out this form. Assistance depends on the availability of funds which come from donations to our charity. All donations are tax-deductible. We would love if you could help promote our organization to your friends and family so we can continue to offer assistance.

Pillars of Light and Love is located at 511 W Main St. Trappe, PA 19426 Phone: 484.854.1162 Email: 

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Email *
Name of Person Completing this Form *
 Name of Person in Need of Services: *
What is your relationship to person in need? *
Date of Birth of Person in Need: *
Street Address of person in need of services: *
City, Street, & Zipcode: *
Cell Phone Number of Person Completing Form: *
Do you have health insurance? *
If yes, please provide the name of the carrier: *
Which of the following issues are you experiencing? (please select all that apply) *
Please select services you feel would benefit you: *
The services offered at the Empowering U Center range from $60 to $125 per hour. Please check off the amount that you are able to pay per session. The more that you can co-pay, the more services/sessions you may be able to receive *
Please provide your total household income: *
Please briefly explain your need for personal services, your financial challenges and your goals of what you hope to gain from the services: *
PLEASE READ THE FOLLOWING:  Pillars of Light and Love is a 501 (c)3 Non-Profit with a dedicated amount of funds to be used for services at the Empowering U Center in Trappe, PA. Funds are available for those facing financial hardship, as well as those with serious illness or disability, caregivers of those with special needs, disabled veterans, and others, as may be determined by our board of directors. All service providers are certified in their respective field, or approved by us, and are insured, if applicable. We are not a medical establishment, nor do we diagnose or treat diseases. If you have a physical or mental condition, you should speak with your physician. You should also consult your physician prior to receiving any of our services. We offer no guarantee that services will be successful. It is the policy of this organization to provide equal opportunities without regard to Race, Color, Religion, National Origin, Gender, Sexual Preference, Age, or Disability. By submitting this application, I affirm that the facts set forth above are true and complete. I understand that if I am to be accepted for services, any false statements, omissions, or other misrepresentations made by me on this application may result in service cancellation and repayment in full for services received. Your application will be seen by our Administrator, and reviewed by our Founder who makes the decision. Your request may be discussed with various practitioners at the Empowering U Center in order to figure the best assistance for you.  By checking the "yes I agree" box below, you agree to this paragraph in its entirety: *
NAME OF PARENT OR GUARDIAN for those under 18
FOR APPLICANTS UNDER THE AGE OF 18: by checking the yes box below, you are acknowledging that you are responsible for the minor who is an applicant and agreeing the minor has your parental/guardian consent to apply for financial assistance at Pillars of Light and Love and you have read the agreement in its full entirety:
Parent Cell Phone Number:
Parent Email Address:
Please provide any additional information that you think would be beneficial for us to know to determine services and assistance for the applicant: *
A copy of your responses will be emailed to the address you provided.
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