Theragrace Partnership Application "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Program Purpose Theragrace provides temporary financial assistance to support continuity of care for clients experiencing employment or insurance gaps. This application is for licensed therapists seeking to partner with Theragrace on behalf of their clients. Therapist InformationFull Name*Professional License Type & NumberState(s) Licensed InPractice Name (if applicable)Phone NumberEmail Address Practice Address Street Address City State / Province / Region ZIP / Postal Code Professional Background Primary Area(s) of Practice Individual Therapy Couples Family Group Other Please SpecifyYears in PracticePopulations Served (check all that apply) Adults Adolescents Children Couples Families Other Please SpecifyBrief Description of Therapeutic ApproachClient Need & Eligibility Do you currently have clients experiencing financial hardship due to employment gaps? Yes No This field is hidden when viewing the formEstimated number of clients who may benefitTypical session feeSliding scale offered? Yes No If yes, rangeParticipation Agreement As a Theragrace partner, I agree to: Provide accurate information regarding client need Offer services at an agreed reduced or consistent rate when applicable Maintain all ethical and legal standards of care Notify Theragrace of any changes in client eligibility Collaborate as needed to support continuity of care Payment & Coordination Preferred Payment Arrangement: Direct payment to therapist Reimbursement model Client subsidy (client receives support directly) No, I want to become a provider Preferred Method of Communication: Email Phone Consent & Attestation I certify that all information provided is accurate to the best of my knowledge I understand that participation in the Theragrace program is subject to review and approval I agree to comply with all applicable laws, regulations, and ethical standardsSignature SignatureDate MM slash DD slash YYYY
