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Apply for a Care Scholarship

We’d love to hear from you! Please reach out to us using the contact form.

Care Scholarship Application

To apply for a care scholarship which can support you with you with funding assistance for therapy and assessments, please complete the form below. Our team will be in touch if we require any additional information.

Applicant Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender Identity(Required)

Male

Female

Non-Binary

Prefer not to disclose

Other

Preferred Pronouns(Required)

She/Her

He/Him

They/Them

Other

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Contact Method(Required)

Phone

Email

Text

Mail

Are you currently experiencing housing insecurity or other urgent needs?(Required)

Yes

No

Parent/Guardian Information (if applicable)

Name

First Last

Relationship to Applicant

Phone

Email

Referral Source

How did you hear about Inclusive Minds Foundation?(Required)

Website

Social Media

School/Educator

Healthcare Provider

Friend/Family

Other

Support Requested

Which type(s) of care are you seeking scholarship support for?(Required)

Psychological assessment

Therapy

Executive functioning coaching

Group support / Retreats

Select all that apply.

Please describe your current situation and what kind of support you’re seeking:(Required)

Have you already been in touch with a provider or do you need help finding one?(Required)

I have a provider

I need help finding one

I'm not sure

Financial Information

What is your total household income (before taxes)?(Required)

Less than $25,000

$25,000-$50,000

$50,000-$75,000

$75,000-$100,000

Over $1000

Number of People Supported by This Income(Required)

Do you currently receive any of the following?(Required)

Medicaid

Medicare

SSDI/SSi

SNAP/Food Assistance

Housing Assistance

None

(Check all that apply)

Do you have health insurance?(Required)

Yes

No

What type of health insurance?(Required)

Medicaid

Marketplace

Private Insurance

Through Employer

Other

Do you have out-of-network coverage?(Required)

Yes

No

I'm not sure

Do you have a Health Savings Account (HSA) plan?(Required)

Yes

No

I don't know

Is there anything else you’d like us to know as we review your application?

Would you like to be added to our newsletter to hear about future resources and opportunities?(Required)

Yes

No

Confidentiality Statement

All information you provide is kept confidential and used solely for the purpose of scholarship consideration and care coordination.

Attestation Statement

I confirm that the information I’ve provided is true to the best of my knowledge, and that I am applying in good faith.

Four (4) + Two (2) =

Phone

This field is for validation purposes and should be left unchanged.

Creating opportunities and supportive spaces for neurodivergent individuals through advocacy, education, and employment initiatives.

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Inclusive Minds Foundation is a nonprofit organization with designation as a tax-exempt organization by the Internal Revenue Service (ID# 33-1620114).

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