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Affinity Healing Collective 501(c)(3) Funding Application

This application is for funding requests to support therapy services for clients or to provide funding for therapists to cover training, respite, or paid time off (PTO).

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If you experience any issues with the online application, send a direct message to info @ affinityhealingcollective.com.

Affinity Healing Collective 501(c)(3) Funding Application - For Therapists

Section 1: Therapist Information

Full Name:

Phone/Mobile

Therapist’s License:

Licensed

Pre-Licensed

Unlicensed

License Type (Check one):

Licensed Professional Counselor (LPC)

Licensed Clinical Social Worker (LCSW)

Licensed Marriage and Family Therapist (LMFT)

Licensed Psychologist

Pre-licensed Associate (e.g., Associate LPC, Associate MFT)

Unlicensed

License Number & State:

If pre-licensed or unlicensed, provide Supervisor's Name:

Section 2: Funding Request

Purpose of Request (check only one):

Training

Respite

If Applying for Training Funding:

Name of Training:

Training Location:

Training Date(s) and Time:

Training Focus:

Marginalized Populations

Trauma

BIPOC Providers

LGBTQIA+ Providers

Other:

If other, please specify:

Additional Requirements:

Email a copy of the training flyer or a link to the training website to us at info@affinityhealingcollective.com
Submit the application at least two months before the training.
Check the box below to confirm:

Submit Confirmation of Attendance

I agree to submit confirmation that I attended the training for the intended purposes. If confirmation is not submitted, I will return the funding.

If Applying for Respite Funding:

Amount Requested:

Days Requested for Respite:

Respite Purpose:

Section 3: Acknowledgment and Signature

Required checkbox:

I acknowledge that the information provided in this application is true and accurate to the best of my knowledge. I agree to abide by the conditions of funding, including providing supplemental documentation with this application and submitting proof that the funding was used for the intended purposes.

Signature

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