Counseling Grant Program Application

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Counseling Grant Program Application

Name(Required)

First Last

Date of Birth:(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Marital Status(Required)

Single

Married

Widow

Domestic Partner

Email(Required)

Last employer(Required)

Date of last employment(Required)

Do you currently have health insurance including COBRA?(Required)

Yes

Number of Household members(Required)

Household income before COVID-19(Required)

Household Income after COVID-19(Required)

Reason for requesting therapy(Required)

Do you currently have a therapist?(Required)

Yes

If yes, who is your therapist?

Is there anything else that you would like to share about your current situation that would help us to better understand your need?

By applying for this grant, I acknowledge:

That the above information that I provided is true and correct.
Sessions are limited to no more than 5 per applicant.
The funds from Project HOPE may only be used for the mental health services provided by an SSL vetted and approved licensed mental health professional.
Once accepted and grant funds are awarded from the Project Hope Program: Must be started within a couple of weeks from date of acceptance and completed within 60 days.
That I have read and accept the terms and conditions of the SSL Foundation Responsibility and Disclaimer: The processing and review of applications, and determinations regarding awards and payments of grants, are subject to the sole and absolute discretion of the SSL Foundation. Applicants must acknowledge that grant funds will be awarded by SSL in its sole discretion and without recourse to the SSL Foundation regarding any determinations, funding decisions, awards, payments, mental health services or other matters related to or arising out of the SSL Foundation’s Project Hope Grant Program and applications will include a waiver and hold harmless/indemnity provision. SSL Foundation reserves the right to modify, suspend or terminate the Project Hope Grant Program at any time.
Grant Payments: SSL Foundation will notify the applicant of acceptance into the Project Hope program. Grant recipients will be provided with a referral to a vetted and approved mental health professional.SSL Foundation will disburse funds to the providing therapist once appropriate documentation has been received by SSL Foundation.
Individual grants hold no monetary value and may not be transferred.