LTCC counseling scholarship application
Please read carefully and thoughtfully. Please be sure all items are completed, as this will prevent any delay in processing your application.
Email address *
What is the Life Transformed Scholarship Fund?
At Life Transformed, part of our mission is to provide Christian counseling to clients and make our services available to those who might have difficulty affording them. This fund's purpose is to subsidize a portion of your fee if you are in significant financial need. This fund does not make counseling free, but it reduces the portion you will pay for treatment.
First Name *
Last Name *
Age *
Contact Phone *
Street Address *
City *
State *
Zip *
Total Household Income per year (gross) $ *
Monthly Mortgage/Rent $ *
Monthly Utilities $ *
Monthly Car Payment(s) $ *
Outstanding Credit Card Debt $ *
Current Occupation(s) *
It is the policy of LTCC that applicants provide MUST provide verification of income such as an income tax form, pay stub or similar proof. Please bring your support documentation to your first session. Without the documentation, your counselor will not provide treatment.
By clicking "yes" below, I indicate that I understand the above stated requirement. *
Required
Are you currently involved in a church?
Clear selection
if so, where?
Have you contacted your church?
Clear selection
If not, are you okay with LTCC reaching out on your behalf?
Clear selection
Have you contacted extended family or friends for possible financial assistance for counseling?
Clear selection
Reason for seeking counseling *
Please explain any significant extenuating financial circumstances *
I found your practice through
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Counseling Scholarship Agreements
I understand that in order to receive financial assistance from the LTCC's scholarship fund, information about my financial resources will be reviewed by one of our counselors.
I understand that it is my responsibility to keep life transformed updated should my financial status change.
I understand that LTCC's scholarship funds do not cover the cost of unexcused, missed or canceled (with less than 24 hours notice) sessions, and that I will be charged for my co-pay amount for the session.
It is the LTCC policy that assistance through this scholarship fund may be approved for a period of 6 sessions, followed by a financial and progress review.
I further understand that if I am granted scholarship funds, I cannot file any claims with my insurance company. This is considered insurance fraud.
By clicking "yes" below, I indicate that I agree to these terms and conditions. *
Required
Thank you for your responses. We will be in contact shortly. Take care.
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