TREATMENT SCHOLARSHIPS

TREATMENT SCHOLARSHIPS

The Peace of Mind Treatment Scholarship program is currently filled to capacity, and all scholarship applicants are currently being placed on a wait list.

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Email Address:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip Code:
Country:
Date of Birth:
Home Phone:
Cell Phone:
Age:
Legal Guardian Name (if applicable):
Annual Household Income:
Do you give consent for the Peace of Mind Foundation to contact your therapist in order to obtain treatment information?:
Type of Treatment:
Current Doctor or Therapist:
Your Doctor/Therapist's Contact Information::
Current Insurance Provider and Plan:
Reason why you feel that you need a scholarship for your treatment of Obsessive Complusive Disorder:
Have you been previously treated for OCD, if so when/where/and for how long?: