[vc_row][vc_column width=”1/4″][/vc_column][vc_column width=”1/2″][vc_column_text][/vc_column_text][/vc_column][vc_column width=”1/4″][/vc_column][/vc_row][vc_row][vc_column width=”1/4″][/vc_column][vc_column width=”1/2″][vc_column_text]

Partner Program Application

[/vc_column_text][/vc_column][vc_column width=”1/4″][/vc_column][/vc_row][vc_row][vc_column width=”1/4″][/vc_column][vc_column width=”1/2″][vc_column_text]Our mission at The Loa Fund is to provide financial support to qualified individuals or programs who would stand to benefit from mental health or addiction services, including education, prevention, and treatment.

The following information and questions serve as an invitation to join us in fulfilling this mission. As an official Loa Fund program, there are expectations that we have in place to ensure the money we raise is creating the maximum possible benefit to grant recipients.[/vc_column_text][/vc_column][vc_column width=”1/4″][/vc_column][/vc_row][vc_row][vc_column width=”1/4″][/vc_column][vc_column width=”1/2″][vc_column_text]

Order Number

Program Name *

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First Name *

Last Name *

Job Title

Email Address *

Contact Number *

Alternate Contact Number *

Describe Your Program *

Tell us about who you serve and how you serve them

Upload Relevant Informational Print Materials About Your Program

Add File Upload material in PDF format.

What treatment approaches does your program use? Modalities?

Describe theoretical approaches and forms of treatment commonly used.

What facilities and environments does your program utilize?

Describe the typical clinical presentation of clients entering your program.

Discuss common diagnoses, health status, living situation, etc.

What type of family involvement is expected of program participants and their families?

How would you describe the ideal scholarship recipient for your program?

Information Summary

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