Scholarship Application: Pregnancy Loss for Psychotherapists

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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: June 23 and July 13, 2020

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Zip *

Profession *

Employer *

Education/Credentials *

Please list the counties you serve.

Briefly describe your involvement in perinatal mental health:

Please write a brief statement about how this training will be used in your practice:

Please write a brief statement about how you plan to provide services to underserved communities:

Please write a brief statement about how you hope this training will impact your community or community you serve:

Briefly describe if you serve low-income or otherwise underserved communities (please quantify by give number of clients or percentage of caseload).

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. )

I have current openings in my practice and agree to take new clients with Medicaid over the next 12 months after the training. *

Yes

Other:

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