Milford Church of God
Counseling - Discount Scholarship Application Form
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Explanation
Through the generosity of Eagle’s Wings Counseling, legacy giving from past clients and other donations we are able to offer discounts greater than 30% to those with an annual income of less than $30,000 / year.
Personal Information
All information you provide will help to determine if you qualify for a discount greater than 30%. All information you provide will be kept strictly confidential.
Please enter your name
required
First Name
Last Name
If your spouse is receiving counseling with you please enter his/her name
required
First Name
Last Name
Your best contact phone number
required
Phone Number
Best email to contact you at
required
Email Address
What is your total current family income? Please indicate amount entered as weekly, monthly, or annual amount - whichever is easier for you.
required
***Please bring a copy of your last two pay stubs for income verification purposes.
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THIS SECTION: Only for those under extreme financial hardship
Is your total monthly family income less than $1,000 per month?
select one
Select from list
YES
NO
If YES to previous question
The current schedule allows for two pro bono (low to no cost) clients per month. There is usually a waiting list for those who qualify.
If you think you may qualify for this kind of scholarship please indicate below the amount per session you can afford.
required
* required
