High Fives Foundation | Mental Health Services Grant

Demographics

Collected for statistical purposes only.

Name

Email

Phone

Physical Address

Mailing Address

Age

Why are you requesting funding for mental health services?

I do not have insurance.I have insurance, but my practitioner of choice is out of network. Other - please describe.

If "Other" please describe

Name of your practitioner of choice.

Practitioner of choice's website

Practitioner of choice's contact information (email or phone).

The statements and answers given in this grant application are true and

correct. I understand that misstatements in this grant application could

cause my application to be denied. The High Fives Foundation reserves the

right to deny applications based on discretion.

I Understand