James Bosch Therapy Grant Contact Us - Alisa Ann Ruch Burn Foundation

AARBF recognizes the long and complex journey that a burn survivor, family member or caregiver undertakes as a result of a burn injury. In some cases, AARBF is able to provide financial support to survivors and family members/caregivers seeking therapeutic counseling. Please complete this application and submit. Your regional manager will contact you for additional information

Personal information

First Name

Last Name

Email

Phone

Address

Street

City

State

Zipcode

Tell us more about you

Burn Survvor

To which gender do you most identify?

Date of Birth

Do you have medical insurance?

Yes
No

Will your insurance pay for a portion of services?

Yes
No
Don't know

Have you ever seen a therapist or psychological counselor before?

Yes
No

Are you able to commit to seeing a therapist regularly for a minimum of six months?

Yes
No

Please describe any topics or goals you would like to address within counseling

Do you have a therapist that you would like to work with?

Yes
No

Do you have any preferences in a therapist? (example: gender, location, etc.)

Which grant are you applying for?

First time applying: $1800 grant - Maximum of $300/month
Reapplying $900 grant - Maximum $150/month

Consent Agreement

I understand that, if awarded a therapy scholarship, AARBF will pay my therapist directly until the dedicated funds have been disbursed. While AARBF will send me and my therapist reminders and updates, I will be responsible to cover the costs of any services that go above and beyond the therapy scholarship award that I receive. If I am unsure of how much of my scholarship remains, it is my responsibility to contact AARBF to find out. If I fail to attend therapy for two months, I understand that the funds will be reallocated to someone on the waitlist.

Multiple Choice

Yes, I understand and agree to the terms outlines above in the participant agreement
No, I do not agree to abide to the participant agreement