Scholarship Application: Pregnancy Loss for Psychotherapists
Limited Scholarships available for those providers who meet the following requirements:
1. Take 1 or more Medicaid (Apple Health) plans and
2. Agree to continue to take new clients with Apple Health plans for a year.
3. Work within communities who have historically been underserved and have the necessary connection to serve families in those communities.

Full and partial scholarships are available. To apply, please fill out the form before.

There are two scholarship deadlines to be considered: March 23rd and April 6.
First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Email *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Profession *
Your answer
Employer *
Your answer
Education/Credentials *
Your answer
Please list the counties you serve.
Your answer
Briefly describe your involvement in perinatal mental health:
Your answer
Please write a brief statement about how this training will be used in your practice:
Your answer
Please write a brief statement about how you plan to provide services to underserved communities:
Your answer
Please write a brief statement about how you hope this training will impact your community or community you serve:
Your answer
Briefly describe if you serve low-income or otherwise underserved communities (please quantify by give number of clients or percentage of caseload).
Your answer
If you have not incorporated the 3 criteria into your answers above please explain here how you meet all the criteria (Take 1 or more Medicaid (Apple Health) plans, please specify which plans and work within communities who have historically been underserved and have the necessary connection to serve families in those communities. )
Your answer
I have current openings in my practice and agree to take new clients with Medicaid over the next 12 months after the training. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Perintal Support Washington. Report Abuse