JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
EXPLORE Scholarship Application
Please provide the following information about yourself.
Sign in to Google
to save your progress.
Learn more
Full Name & Email
Your answer
Where do you live?
Your answer
What are you hoping to get out of EXPLORE?
Your answer
What are you currently doing to support yourself?
Your answer
Are you or have you in the past worked with any therapists or practitioners of any kind?
Your answer
What is your annual household income?
Undering $20,000
$20,000 - $30,000
$30,000 - $40,000
Over $40,000
Are you financially supporting anyone other than yourself? (ie have children, other family members or friends you provide financial support or care for?)
Your answer
Have you ever been given a scholarship before?
Your answer
What are some of things that may get in the way of you participating in this program?
Your answer
What survival patterns and/or trauma are you aware of that influence your ability to participate in this program?
Your answer
Why do you want to participate in EXPLORE and what are some ways that you can hold yourself accountable for showing up and doing the work?
Your answer
Is there anything else you'd like me to know?
Your answer
Thank you SO much for taking the time for sharing a bit about yourself and your interest in doing EXPLORE. I will review your application as soon as I can and will get back to you with some options. Wishing you capacity. Nicole
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Nicole Lohse.
Report Abuse
Forms
