Neurotherapy for Mental Health Grant Application

Individuals who suspect their challenges are arising from less than optimal brain regulation leading to unwanted impacts on quality of life, school or work-related performance, relationships, or success navigating the world are encouraged to apply.

To be eligible, individuals must demonstrate financial need and have exhausted other financial assistance options.

The application can be initiated by the client’s treatment team or the client themselves. When possible it’s optimal to include the following information: documentation of diagnosis, treatment plan, and financial information.

If application is being submitted by a potential recipient (not by a mental health professional), the recipient must submit a 500 word summary of why they are wanting to participate in neurotherapy. *Applicant may choose to submit video in lieu of written summary if written summary would deter access. File may be sent to [email protected]

First Name *

Applicant First name

Last Name *

Applicant Last Name

Date of birth *

Applicant Date of Birth

Address

Street Address

City

State

Postal Code

Phone *

Applicant Phone #

Email *

Applicant Email

Referring Professional and/or Organization Name

Referring Professional's Emai

Referring Professional's Phone

Summary of Supporting Documentation from Referring Professional

Please submit a 500 word summary of why applicant wants to participate in neurotherapy

If applicant is unable to submit a written summary, they have the option to send in a video summary instead. Please send file to [email protected].

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