About our organization:

Contact information of person you are applying for (if not for yourself):

Please note: A separate application must be made for each individual requiring therapy services. 

Declaration:

I declare that I am financially unable to pay for therapy services at Genesis Family Foundation LLC ($85 or more). The issue described above is too severe that I cannot wait with getting help for the applicant until I have sufficient funds. I give permission to the Genesis Family Private Operating Foundation to share my presenting problem, WITHOUT sharing personal data, to potential donors/sponsors that might be willing to

pay for my therapy. 

I give Genesis Family permission to reach out to third parties whom are known (potential) sponsors with a message along the lines of: “Someone is in need of your help today. He/she is struggling with [insert presenting problem], and cannot receive the help they need without sufficient funds to provide for a therapy scholarship.”

Please note: Genesis Family will never identify you, share your contact information or any other personal health information with third parties.

Financial information (on which to prove financial inability to cover therapy expenses): 

Please note: When scholarship is offered, we require a copy of 2 recent pay stubs of the client and/or client’s sponsor(s) before the scholarship is confirmed.

I declare that all information I have provided on this application is correct and true to the best of my knowledge. 

(if 16 years or older, consent of client him/herself is required by Texas law.)