Empowered Relief Scholarship Application

Three scholarships are awarded per workshop, primarily based on financial need. Scholarship entails a 50% discount in registration cost. Scholarship awards are made at the discretion of the Empowered Relief® team. Scholarship applications may be submitted at any time. Note that scholarship awardees will be notified at least 30 days prior to the workshop date. As such, we strongly recommended that your application be received 5-6 weeks prior to your desired workshop date. Early submission will give you an advantage in the review process.

Only licensed clinicians are eligible for scholarship. Please contact us if you have questions about your eligibility.

First Name

Last Name

Email Address

Telephone Number (including country code)

Degree

Bachelor's degree
Master's degree
Doctoral degree (PhD, PsyD, EdD, DSW)
Professional degree (JD, MD, DMD)
Other

Are you a licensed clinician?

Yes
No

In which state are you licensed?

Please give the name of your licensing board and link to their site.

What is your license type?

What is your license number?

Only licensed clinicians are eligible for scholarship. Please contact us if you have questions about your eligibility.

Geographic Location

City

State

Country/Region

What is your primary clinical setting?

Private clinic
Community mental health clinic
Academic medical center
Other

What is the primary population you treat or work with?

Why do you want to become an Empowered Relief certified instructor?

Why do you need a workshop scholarship?

What is your preferred workshop date?

What is your preferred workshop date?
	Month	Day	Year



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In the event that you do not receive a scholarship for your preferred workshop date, would you like us to consider you for scholarship for a future workshop date?

Yes
No