Queer Wellness Center Scholarship Application

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Thank you so much for your interest in QWC scholarship funding. We will try to meet everyone's need with the funding we have available. Scholarships are only available to those without insurance. Please fill out the following form and someone will be in contact with you.

*Disclaimer: You can have up to 16 sessions within a 12-month period per person for therapy sessions. For medical expenses, QWC is able to provide $500 worth of funding.*

Name *

Pronouns: *

Date of Birth *

YYYY

Address *

Phone Number *

Email *

Please explain your financial barriers and the reason you are requesting scholarship funding. *

What type of services do you need help funding? *

Therapy

Medical Service

Other:

Physician Information: *

Amount requested:

Any other questions or comments: *

Please read following statement carefully; I hereby authorize 864Pride to contact my provider on my behalf, for the payment of my service. This also covers any payment changes from initial consultation. If for some reason 864Pride is unable to provide payment I understand I would need to provide payment. I am aware that I can only obtain 16 sessions every 12 months.
*

I have read the statement and fully understand

Required

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