Scholarship Questionnaire

Thank you for your interest in my holistic psychiatry practice. This Scholarship Questionnaire helps me determine whether you will be a good fit for my holistic psychiatry practice and whether a scholarship can be provided to help mitigate the cost of treatment. Because scholarships are provided only if available, not everyone who fills out this questionnaire will receive a scholarship. After entering some basic information, please answer each question to the best of your ability:

First Name

Last Name

Middle Name

If none, write "N/A"

Please provide your initials

This is so I can match it with the Initial Intake Form, which does not have an ID attached to it (that you will fill out next, below.)

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Email Address

1. Why are you seeking a holistic psychiatric approach?

2. How committed and interested are you in this holistic approach? Please describe what you have done in the past that demonstrated a commitment to a holistic approach.

3. Are you willing and able to meet once per week for an hour-long session in order to appropriately support your healing process?

4. Does your insurance cover for out of network psychiatric services? If so, what is your deductible and what is the reimbursement for a “reasonable and customary charge?”

5. Do you currently have a job? How long have you worked in your position?

6. What is your yearly income? Can you provide proof of your income through last year’s tax return?

7. Do you have dependents or other circumstances that necessitate financial support for this treatment?

8. Can you provide your current credit score?

9. Are you able to afford the additional cost for a supplement regimen (approx. $200.00 to $300.00 per month) for treatment?

10. What have you done to obtain other financial support for this treatment?

Scholarship Questionnaire

Thank you for taking the time to provide your answer these questions and for your interest in my holistic psychiatry practice.

Copyright © 2025 Alice W. Lee, MD, ABIHM
Holistic Psychiatrist in Salt Lake City, Utah

All Rights Reserved