Fieldstone Counseling Scholarship Application Form
Fieldstone scholarships are granted on a case by case basis and a sliding scale is used to determine the suggested donation amount. Please contact your local church and inquire about their ability to assist financially before requesting aid through Fieldstone. After checking with your local church, you can apply for a reduced fee with us.

Fieldstone scholarships and reduced counseling rates are effective for 10 counseling sessions. After this point, we will work with you to reassess your needs.

This form should be completed AFTER a Fieldstone Intake Form has been submitted. Scholarship applications that are submitted without an Intake Form on file can not be considered and will remain on hold until an Intake Form is submitted. To fill out an Intake Form please visit our website,

After completing this form please email a scanned copy of your paycheck or first page of tax return to

Questions? Please contact the Fieldstone Finance department 330-896-7204 for more information, or email the address above.
Email *
Have you completed a Fieldstone Counseling Intake form? *Intake forms are required to begin the counseling process. If you are seeking a scholarship for an event or support group please select option 3.* *
Have you contacted your local church to inquire about their ability to assist financially? *
Name of event or group you are seeking a scholarship for (if applicable): *
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