Counseling Therapy Grants Application Row concave-2 Shape Decorative svg added to top "*" indicates required fields Step 1 of 5 20% Adopting Father’s Full Name* First Last Adopting Mother’s Full Name* First Last Home Address (Mailing Address)* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Primary Contact:* Father Mother Adopting FatherPhone*Email* Untitled*Date* MM slash DD slash YYYY Adopting MotherPhone*Email* Untitled*Date* MM slash DD slash YYYY Years You Have Been Married*Name and Age of Children*Adopted Child NameChild AgeGenderCountry/Location Add RemoveName and Age of Children*Biological Child NameChild AgeGender Add RemoveType of Adoption:* Intercountry Domestic Church Name and Denomination*Does your church have an adoption ministry?* Yes No Please provide contact details*How did you hear about us?* Counseling InformationSummarize your family’s adoption journey*Why are you seeking counseling?*Tell us about your support system and relationships with your family*What are your goals, expectations and/or hopes for the healing process?*Have you identified a counselor already? What, if any, experience do you have with them?*Please provide a letter from your selected therapist stating their credentials and modalities to address their competency in working with trauma and adoption.*Max. file size: 2 GB. Counseling Details*Any current financial circumstances that we should take into consideration?*Have you asked about a sliding scale fee for your provider? (This is not usually advertised, but your counselor might offer if asked)* Yes No Does your medical insurance cover any counseling?* Yes No Anticipated Counseling Costs:Counseling Fees Per Session*Frequency of Sessions:* Add RemoveMonthly Cost of Counseling:*How will you fund these costs:Personal Funds*Other:* Add RemoveTotal Estimated Resources* Statement of Net WorthAssetsCash*Checking*Savings*Investments:Stocks*Real Estate (other than your home)*Retirement Accounts*Value of Home (if owned)*Value of Autos*Other:* Add RemoveTotal Assets*LiabilitiesOutstanding Credit Card Balances*Student Loans*Home Mortgage Balance*Auto Loan Balance*Any Other Bills/Amounts Owed:*Bills/Amounts Owed$ Add RemoveTotal Liabilities*Total Net Worth (Assets – Liabilities)* Cash FlowIncome (Please note net income is after taxes, 401K, healthcare and other witholdings)Monthly Net Salary/Wage*Other Monthly Income:* Add RemoveTotal Net Income*Expenses & PaymentsChurch/Charitable Giving (Tithe)*Debt Repayment (not including mortgage)* Housing: Mortgage/Rent*Home/Rental Insurance*Utilities*Other*Other$ Add RemovePhone/Internet*Groceries/Food*Transportation: Car Payment*Car Insurance*Gas/Maintenance*Other*Other$ Add RemoveEntertainment/Recreation*Medical Expenses*Child Care*Other*Misc./Other$ Add RemoveTotal Expenses*Cash Flow (Income – Expenses)* Consent FormBy signing this form and submitting this application: Please read closely and respond accordingly We hereby give consent for Pathways for Little Feet to contact the provider/counselor named in this application for the purposes of determining adoption-competency. It is our understanding that information obtained will be used, in part, to determine our eligibility for this scholarship. We also understand and agree that Pathways for Little Feet is not obligated to provide financial assistance based on the willingness to accept an application. If approved for a counseling grant, we understand, accept and agree to use any and all funds received exclusively for legitimate adoption-competent counseling expenses. We agree to provide verification of expenses upon request. We understand, if approved for a counseling scholarship, that we will be required to answer a survey halfway through the scholarship in order to receive the remainder of the scholarship funds. We also agree to submit answers to a final survey at the completion of the scholarship. These brief surveys will help Pathways for Little Feet to tailor the Family Care program to help with post-placement care for more families. Signature of Adopting Father (Print)* First Last Date* MM slash DD slash YYYY Signature of Adopting Mother (Print)* First Last Date* MM slash DD slash YYYY Adoption-Competent Counseling Here at Pathways for Little Feet, we are passionate about adoption-competent and trauma informed counseling because we place top priority on the best interest of the child and family. A great place to start looking for a provider would be the Trust-Based Relational Intervention (TBRI)® practitioners list available online at http://bit.ly/tbri-practitioner-list. While we cannot speak for every provider listed, we are confident in this training program from the Karyn Purvis Institute of Child Development at Texas Christian University (TCU). We also encourage you to connect with your church or local adoption support group for referrals to adoption-competent counselors in your area. Below we have compiled a list of questions and considerations to help you identify the right provider for your family*: Have you had extra training that is specific to adoption? Have you had experience with post institutionalized children? How does trauma impact a child’s development? What types of adoption have you worked with? Domestic infant? Intercountry? Foster to adopt? Transracial? Older child? Open adoption? How do you work with adoptive families What specific approaches have you found that work to help children cope with adoption, loss, and/or trauma related issues? What changes in the daily life of our child and family might we see as a result of the counseling? Be specific about the adoption issues that affect your family The psychological impact of adoption on children and families Loss as a core issue in adoption and how children process loss at different stages of development The impact of trauma on children and families (results from traumatic experiences prior to the adoption) The role and impact of attachment on the mind and body of the developing child *Child Welfare Information Gateway; TBRI®; Creating a FamilyCAPTCHA Δ
