Counseling Scholarship Application

The following information will help Project NICU determine your eligibility to be awarded our Counseling Scholarship to continue services with BetterHelp.

All information is managed by a Licensed Mental Health Counselor within Project NICU, is considered highly confidential, and will not be shared.

Name

First Name

Last Name

Date you attended your first therapy session with your Counselor through BetterHelp:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How do you identify your race & ethnicity:

Please tell us about your household & family:

Are you the Parent of a baby currently in the NICU?

If yes, what day was your baby born?

Are you the parent of a baby who has graduated from the NICU?

Are you a Bereaved Parent?

Are you a Medical Professional working in the NICU space?

If yes, what is your discipline and title?

Are you currently employed?

Please share some information about your NICU journey with us…

Do you have private health insurance, provided by your employment, your partner's employment, self-purchased, etc.?

If yes, do you have Mental Health Care benefits?

Do you have Medicaid?

Do you receive any other sort of Health Insurance financial assistance or voucher?

Why are you applying for this Counseling Scholarship?

Tell us how the Counseling Program has benefitted you so far

Have you ever been diagnosed with a Mental Health Disorder as an adult?

Have you ever received Mental Health Counseling as an adult? (other than Project NICU’s complimentary services through BetterHelp)

All personal and identifying information shared in this application will be considered highly confidential, and exclusively managed by the Director of Project NICU’s Counseling Program (a Licensed Mental Health Counselor).

*Project NICU will never share this information nor confirm/deny that you are receiving mental health services with anyone, without your explicit approval. Non-identifying statistical and demographic information may be used to help secure future funding to help support the Counseling Program.

Counseling Scholarship Application

The following information will help Project NICU determine your eligibility to be awarded our Counseling Scholarship to continue services with BetterHelp.

All information is managed by a Licensed Mental Health Counselor within Project NICU, is considered highly confidential, and will not be shared.

CONTACT US

CONTACT@PROJECTNICU.COM