Educator Scholarship Application

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We are offering a limited number of reduced fee slots for our mindfulness group, based on a sliding scale according to household income.

Please fill out this application as thoroughly and as accurately as possible, to the best of your knowledge. One of our co-counselors will reach out to you within 48 hours of your submission to discuss your scholarship status.

If you have any questions, please feel free to contact us at 678-235-8968 or kpiercecounseling@gmail.com.

Please note that all information submitted is protected by HIPAA law.

Did you fill out the registration form? *

If no, please complete that form after you submit this one.

Yes

Name *

Email address *

Phone number *

Job Title *

Employer *

Gross annual family income per year *

Number of people dependent on this income *

Household occupants *

List name, age, and relationship to you of everyone currently living in your household. Include housemates, spouse, partner, and all children. Include any different last names, and if minor is from two households.

Name and age of dependents not currently living with you *

Please describe your reason for requesting a reduced fee for services. Include any extenuating circumstances you would like us to consider. *

Is there anything else you would like us to know?

Electronic signature (Type full name) *

By typing your legal name below, you are giving your electronic signature stating that the information submitted is true to the best of your knowledge.

Submit

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