The
Natasha Huelskamp
Scholarship

The Natasha Huelskamp Scholarship Application

Applicants First name

Applicants Last name

Applicants Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Is someone assisting you with filling out this application? If yes, please include their name, relation to you, phone number?

Phone

Please explain why you feel you need Supportive Housing and Services and how this opportunity can benefit you. Please be specific.

Do you have a psychiatrist you see on a regular basis? If yes, please include their name, address, and phone number.

Do you have a therapist you see on a regular basis? If yes, please include their name, address, and phone number.

Are you currently in a hospital or residential treatment program? If yes, please include the name, address, and phone number.

Are you currently enrolled in a PHP or IOP Program? If yes, please include the name, address, and phone number.

Please list two (2) immediate family members as personal references. Please include their names, phone numbers, and their relationship to you.

Are you willing to complete a phone assessment to determine if you meet criteria for our housing and services?

Most recent tax return

Last 3 months bank statements

Wage statement