Application for Financial Assistance at the Empowering U Center

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If you are in need of financial assistance for services at the Empowering U Center, it may be available through Pillars of Light and Love, a non-profit at the Empowering U Center. Please complete this form. Assistance depends on the availability of funds which come from donations to Pillars of Light and Love.

If you receive assistance, we ask that you help others in need by promoting our organization to your friends and family so we can obtain donations to continue to offer assistance.

Pillars of Light and Love is located in the Empowering U Center at 511 W Main St. Trappe, PA 19426 Phone: 484.854.1162 Email: Staff@PillarsofLightandLove.org

Email *

Today's Date *

YYYY

Name of Person Completing this Form *

Name of Person in Need of Services: *

What is your relationship to person in need? *

Self

Other:

Date of Birth of Person in Need: *

YYYY

Street Address of person in need of services: *

City, Street, & Zipcode: *

Cell Phone Number of Person Completing Form: *

Do you have health insurance? *

Yes

Other:

If yes, please provide the name of the carrier: *

Which of the following issues are you experiencing? (please select all that apply) *

Anxiety/Stress

Depression/Overwhelming Sadness

Divorce/Family Conflict

Relationship Issues

PTSD-Post Traumatic Stress Disorder

Overwhelming Grief

Addiction to Drugs or Alcohol

Overwhelming Stress

Terminal Illness Causing Stress, Anxiety, Depression

Bullying

Emotional or Physical Abuse

Caregiver of family member with disability or terminal illness

Physical Disability

Other:

Required

Please select services you feel would benefit you: *

Grief and Loss support

Talk Therapy

Teen & Young Adult Life Coaching with a Young Adult Coach

Marriage or Relationship Counseling

EMDR Therapy for PTSD, Addiction or Anxiety

Biofeedback for stress or anxiety

Other:

Required

The services offered at the Empowering U Center range from $65 to $175 per hour. Please check off the amount that you are able to pay per session. The more that you can co-pay, the more services/sessions you may be able to receive *

$20

$30

$40

$50

$60

$70

Required

Please review the list of services and Practitioner bios at www.EmpoweringUCenter.com and select one or more of our Practitioners below: *

Adrianne Wagner, licensed Marriage & Family, EMDR Therapy

Al, Reith, Biofeedback & Stress Management Specialist

Diane Nolan, Certified Holistic Stress Management & Biofeedback Specialist

Jonathan Ali-Acevedo, non-certified, Teen Coach

Kathy O'Connell, licensed Marriage & Family Therapist

Kristen Murphy, pre-licensed Therapist, PA Horizons Counseling, specialty in trauma & addiction

Nina Aniskevich, Therapist, PA Horizons Counseling, EMDR Therapy

Robert Bingham, Therapist, PA Horizons Counseling, Registered Somatic Movement Therapist

Frank LoRiggio, Licensed Counselor and Certified EMDR Therapist

Other:

Required

Please provide your total household income: *

Under $2,000 per month

$2,000-3,000 per month

$3,000-4,000 per month

$4,000-5,000 per month

Over $5,000 per month

Please briefly explain your need for financial assistance and your goals of what you hope to gain from services at The Empowering U Center: *

PLEASE READ THE FOLLOWING: Pillars of Light and Love is a 501 (c)3 Non-Profit with a dedicated amount of funds to be used for services at the Empowering U Center in Trappe, PA. Funds are available for those facing financial hardship, as well as those with serious illness or disability, caregivers of those with special needs, disabled veterans, and others, as may be determined by our board of directors. All service providers, except for Life Coaches, are certified/licensed in their respective field. We are not a medical establishment, nor do we diagnose or treat illness or diseases. If you have a physical or mental condition, you should consult a physician. You should also consult your physician prior to receiving any of the services at the Empowering U Center. We offer no guarantee that services will be successful. It is our policy to provide equal opportunity without regard to Race, Color, Religion, National Origin, Gender, Sexual Preference, Age, or Disability. Your application will be seen by our Administrator, and reviewed by our Founder, Kathy Opperman, who makes the decision on assistance, and may do so in consultation with a service provider at the Empowering U Center without mention of your name, unless the provider has provided services to you previously. By checking yes below and submitting this application, you affirm that the facts set forth above are true and correct. You understand if you are provided financial assistance that any false statements, omissions, or other misrepresentations made by applicant on this application may result in service cancellation and repayment to Pillars of Light and Love in full for assistance received. *

Yes I agree

No I do not agree

Other:

NAME OF PARENT OR GUARDIAN for those under 18

FOR APPLICANTS UNDER THE AGE OF 18: by checking the yes box below, you are acknowledging that you are responsible for the minor who is an applicant and agreeing the minor has your parental/guardian consent to apply for financial assistance at Pillars of Light and Love and you have read the agreement in its full entirety:

Yes

Other:

Parent Cell Phone Number:

Parent Email Address:

Please provide any additional information that you think would be beneficial for us to know to determine services and assistance for the applicant: *

A copy of your responses will be emailed to the address you provided.

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