Scholarship Request

Apply for a scholarship here.

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Question 1 of 10

Name

Paragraph answer

Question 2 of 10

Email Address

Paragraph answer

Question 3 of 10

City

Paragraph answer

Question 4 of 10

State

Paragraph answer

Question 5 of 10

Country

Paragraph answer

Question 6 of 10

Are you able to read & write in English (enough to communicate effectively)?

Paragraph answer

Question 7 of 10

What are you coming here for help with?

(Select all that apply)

A

Anxiety

B

Anxious Attachment

C

Avoidant Attachment

D

Contamination OCD

E

Depression

F

Fearful Avoidant Attachment

G

Existential OCD

H

False Memory OCD

I

Harm OCD

J

Health OCD

K

Just Right OCD

L

Magical Impregnation OCD

M

Moral Scrupulosity or Religious OCD

N

Pedophilia OCD

O

Peri/Prenatal OCD

P

Pure-O

Q

Racism OCD

R

Real Event OCD

S

Relationship OCD

T

Sexual Orientation OCD

U

Skin Picking, Hair Pulling, Other

V

Somatic/Sensorimotor OCD

W

Suicidal Intrusive Thoughts

Question 8 of 10

Why are you requesting a scholarship (provide as much detail as possible)?

Paragraph answer

Question 9 of 10

Are you able to pay for at least 50% of the program cost?

Paragraph answer

Question 10 of 10

Are you able to pay for at least 25% of the program cost?

Paragraph answer

Confirm and Submit

Name

Email

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