Grief Therapy Stipend Intake Form

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We know how important mental health is to our well being. We want to provide children who need grief therapy services with a stipend to ensure they can get the care they need. The stipend program will cover about 5 therapy sessions. Charlie's Guys will either pay your provider directly for the cost of the sessions or will reimburse you personally upon obtaining a receipt of services provided.

Name of Person Filling out Form *

Email Address *

Phone Number *

Relationship to Child/ren *

Name and ages of children who plan to receive grief therapy services *

Details of lost loved one *

Name of therapy provider *

Website of therapy provider *

Name and Home Address (if we are to send you a check reimbursement for grief therapy services received) *

City *

State *

Acknowledgment: I agree to either send Charlie's Guys my therapy invoices directly or a receipt of my payment for my children's grief therapy services. If I am being reimbursed, Charlie's Guys will send a check directly to my home. *

Yes

The following information we need in order to apply for grant funding. Please check one box that identify the children. *

African American

Asian

Biracial

Caucasian

Indian Asian

Native Hawaiian or Pacific Islander

Latino

Multiracial

Native American or Eskimo

Required

Annual Household Income - for grant demographic purposes only, does not impact your qualifications for our services *

Under $75,000

$75,000-$100,000

$100,000-$150,000

$150,000-$200,000

Above $200,000

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