Scholarship Application

Hello! We are so glad you're here!

Rebuild-A-Bitch offers scholarships (up to $500) for women impacted by cancer to receive mental / physical health coaching support.

WE ARE NOW OFFERING BOTH MENTAL HEALTH AND INTIMACY COACHING!

By completing this application, you agree to share your information with R-A-B and wish to be considered for a mental / physical health scholarship. R-A-B may use your email and / or phone numbers to send you communication about our services or events.

Scholarships are awarded at the end of each quarter (March, June, September, December). The number of scholarships we can provide is directly related to the amount of grants/ funding we receive each quarter. You will receive an automated email directly from the R-A-B Smartsheet account if you are selected to receive a scholarship that will provide you with next steps.

Please note that our mental health coaches are not intended to replace your time with a therapist.

*This scholarship program is only available for women impacted by cancer that live within the continental United States*

Please complete the fields below to the best of your ability.

Full Name*

Please enter your first and last name.

Email Address*

Please provide an email that you check regularly as this will be our primary form of communication.

Phone Number*

Phone

Street Address*

City*

State*

Select or enter value

Zip*

What type of cancer were you diagnosed with?*

What was the date of your diagnosis?*

Are you still in active treatment?*

Select

What is your total annual income?*

We want to help ensure women with limited income can benefit from resources. Please select your income level below, so we can better assess your need.

Select

Coaching Selection*

Please select if you would like to receive mental health or intimacy coaching.

Select or enter value

Intimacy Coach Selection*

Please select your preferred intimacy coach provider.

Provider information can be found here - rebuildab.org/intimacy-coaching.

Select or enter value

First Selection - Resource Provider*

Select your first choice of a mental health coaching provider that you would like to work with.

Provider information can be found here - rebuildab.org/mental-health-coaching. Please note this is not a final selection, but for planning purposes only. We will verify availability and have you confirm a final provider after scholarships are awarded.

Select

Second Selection - Resource Provider*

Select your second choice of a mental health coaching provider that you would like to work with.

Provider information can be found here - rebuildab.org/mental-health-coaching. Please note this is not a final selection, but for planning purposes only. We will verify availability and have you confirm a final provider after scholarships are awarded.

Select

Would you prefer to participate in an individual (1:1) program or a group program?*

Select

What would this scholarship mean to you? Why are you looking to invest in yourself at this time?*

Please tell us what you hope to gain from a coaching scholarship from R-A-B.

Have you participated in a coaching program before?*

Select or enter value

What program / provider did you work with?*

Please provide the name of the provider or program.

When did you participate in this program / work with this coach?*

Are you ok covering a small portion of cost associated with your resource provider?*

Based on funding, R-A-B may not be able to cover a providers cost in full. Please let us know if you are ok spending a little of your own money to invest in yourself.

Yes

Is there anything else you'd like to share with R-A-B at this time?

By checking the box below, I agree that the above information is correct.*

Yes, I confirm my identity as indicated above and wish to receive services from R-A-B.

Send me a copy of my responses

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