Financial Support Pre-Screening Application

Child's First Name

Child's Age

Parent or Guardian's First Name

Parent or Guardian's Last Name

Parent or Guardian's Email Address

Parent or Guardian's Phone Number

Services Needed

Child or Adolescent Psychotherapy

Infant Parent Psychotherapy

Please add below the reason you are seeking psychotherapeutic services for your child at this time and why you would like to be considered for funding support with the WCCFF.

Personal stories are a great way to educate donors about the public's need of services. Please choose one of the two options below:

I agree for my anonymous information to be used for future funding applications or fund raising activities.

I DO NOT agree for my information to be used for future funding applications or fund raising activities.

Thank you for filling out the form. If you wish to add any other information to support your pre-screening application please do so below.

The Willow Centre

Toronto Child Psychologists and Psychotherapists

Financial Support Pre-Screening Application