Scholarship Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Applicant InformationFull Name of Person Seeking Treatment *FirstLastDate of Birth *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Your Relationship to the Applicant *Applicant Background InformationIs the applicant a resident of Texas? *YesNo Has the applicant resided in Texas for at least one year? *YesNoDoes the applicant have a history of criminal charges? *YesNoDoes the applicant have a history of suicide attempts or self-harm? *YesNoIf yes, when was the last attempt or self-harm incident?Does the applicant have a history of drug or substance use/abuse? *YesNoIf yes, which drug(s)?Is the applicant currently using drugs or substances? *YesNoDoes the applicant have a history of aggressive behaviors? *YesNoIf yes, are they currently exhibiting aggressive behaviors?Does the applicant have a history of elopement? *YesNoDoes the applicant have a history of abuse or trauma? *YesNoIf yes, please specify:Diagnosis and Treatment Information:Please provide a brief description of the applicant's mental health diagnosis and history of treatment (attach additional pages if necessary): Visual Text Is the applicant currently receiving any mental health treatment? *YesNoIf yes, please provide the name and contact information of the current mental health provider:Name and contact information of the residential treatment facility you are seeking financial assistance for:Attach a treatment plan or summary provided by the residential treatment facility or the mental health provider. Click or drag a file to this area to upload. Financial Information:Please provide a summary of the applicant's current financial situation, including their monthly income, assets, and expenses (attach additional pages if necessary): *Attach any relevant financial documents (e.g., pay stubs, bank statements, tax returns) to support the applicant's financial need. Click or drag a file to this area to upload. Family Financials: Please provide information regarding the financial situation of the applicant's family or the person filling out the application (if applicable). This section is necessary to review financial support options. Name of Primary Income Earner *Occupation and Annual Income *Additional Sources of Income (if applicable) *Total Monthly Expenses *Number of Dependents *Assets (if applicable) *Scholarship Revocation Clause: The Mental Health Foundation of Texas reserves the right to revoke the scholarship at any time under the following circumstances: · Lack of progress in treatment. · Engagement in criminal activities during the scholarship period. · Discovery of information that disqualifies the applicant from receiving the scholarship based on past actions or qualifications. · Inheritance or acquisition of funds that enable the applicant or their family to afford the residential treatment without the scholarship.Release Form: By signing below, I hereby authorize the Mental Health Foundation of Texas to share my story, including personal experiences and treatment progress, with other donors or potential donors for the purpose of raising awareness and support for mental health initiatives. Applicant's Declaration: By signing below, I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any false statements or misrepresentations may result in the disqualification of my application or the revocation of any awarded scholarship.Name *Date *Submit
