First Name
Last Name
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Phone
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Email
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Address
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City
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State
Country
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Country
Gender
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Gender
Are you currently employed? If yes, please provide details (employer, job position, income, etc.). If no, please indicate your source of financial support (e.g., savings, family, government assistance, etc.):
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Monthly Household Income (yours and your partner's income) in local currency:
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Number of dependents (if applicable):
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Have you been diagnosed with vaginismus by a healthcare professional?:
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As a scholarship recipient, there is the expectation to give back to Pain-free Intimacy in the form of testimonials and feedback. Do you agree to this?
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Yes
No
What previous treatments or therapy for vaginismus have you tried? Please provide details:
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Please explain why you believe participating in the Mind-Body-Sex Reset Vaginismus program would be beneficial for you:
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This program requires consistent dilator work and nervous system work 3-4x a week for about 30-45 min each session. How do you plan to make time for the work involved in this program?
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Describe any financial hardships or constraints that prevent you from affording the vaginismus program and the impact this has had on your ability to seek treatment:
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Date
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By submitting this scholarship application, I certify that all the information provided is true and accurate to the best of my knowledge. I understand that any false information may result in the rejection of my application.
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