Grief Therapy Stipend Intake Form
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.
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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. *
The following information we need in order to apply for grant funding. Please check one box that identify the children. *
Annual Household Income - for grant demographic purposes only, does not impact your qualifications for our services *
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