Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Advance Hope Ministries Scholarship Application This application is requesting financial support in the form of a scholarship for mental health services for those with a financial need and have a financial barrier to receive services. Scholarships are based on a sliding scale fee determined by your income. Scholarship funds are not guaranteed and depend on available funds for distribution. Scholarships are provided through donations from generous donors that believe in coaching or counseling from a Christian worldview. Scholarship funds will be provided for individuals and paid directly to Mental Health providers that register with the Advance Hope Ministries network. A release of information will need to be signed on approved scholarships between AHM and the Mental Health Provider to share dates of service. Personal Details for Individual Requesting ScholarshipName *FirstLastEmail *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth; *Is this application for individual, couple or family services? *IndividualCoupleFamilyIs this an application for a minor? *YesNoIf yes, who is the responsible Guardian?What is the relationship to Guardian?Email Address of Guardian:How did you hear about this Advance Hope Ministries Scholarship? *Mental Health ProviderChurchWebsiteWord of MouthSocial MediaHave you ever received a scholarship from Advance Hope?YesNoDo you attend Church? *YesNoIf yes...where? *Do you have health insurance or an HSA? *MedicaidMedicareHealth Insurance i.e. Mountain Co-op, BCBS, Aetna, Allegiance etc.Health Savings Account or Flexible Spending AccountHigh Deductible PlanNoneTell us about your work? *EmployedUnemployedSelf-EmployedRetiredOtherIf yes...where?Are you a student? *YesNoIf yes...where?Do you live with a disability? *YesNoIf yes...please describe:Are you a veteran? *YesNoPlease tell us about your housing: *OwnRentNoneLive with someone elseHow much do you pay for your rent or mortgage monthly? *What is your monthly income? *Please provide a recent pay stub (if applicable): Click or drag a file to this area to upload. Please provide a recent tax return (top sheet only, showing income): Click or drag a file to this area to upload. How much are your monthly expenses? *Housing size: Adults *12345 or moreHousing size: Children *012345 or moreSelect registered Mental Health Provider:Select oneAdvance Hope Mental WellnessNot listedDo you currently have a Mental Health Provider not listed above? (Counselor, Coach, etc.) *YesNoCurrently SeekingIf yes...who?If your Mental Health Provider is not listed above please include their email address here:How much do you pay per session?How much are you able to contribute towards your mental health per session? *0101520253035404550556065707580859095100+If you qualify for a AHM scholarship all payments will be sent directly to your Provider. Your provider will need to register with us so we know who to pay. Do you authorize us to send a letter of decision to your provider? *YesNoPlease provide any additional information you'd like to be considered for this application:By signing below you are acknowledging that you are providing accurate information about your life and your finances. You also acknowledge you are pursuing a scholarship for counseling or coaching through a faith-based provider. Please note that filling out this application does not guarantee approval and a decision letter may take 2 to 3 weeks. Please note decision letters will be emailed to the applicant. By signing below, you are requesting your information to be reviewed by AHM and a scholarship committee. Additionally, by signing below, you are allowing AHM to contact your mental health provider and provide them with a link to participate in our scholarship program. Providers must be registered to receive funds. Signature *Clear SignatureDate Signed *Custom Captcha- Please answer the question below to hep us reduce spam. *What is 7+3? Submit