APPLY FOR SCHOLARSHIP HELP

First name*

Last name*

Phone Number *

Email Address *

Type of Assistance Needed*

Medication or Procedure Co-pay

CCM Service Co-pay

Grocery or Food Support

Utility Bill Assistance

Transportation to Appointments

Other

Amount Needed

Brief Description of Your Situation

Supporting documents

How did you hear about Juniper Tree?

VitalSigns House Calls clinician

Church or faith community

Senior center or assisted living

Friend or family

Other

I understand that assistance is provided as much as our current resources allow and is not guaranteed.

Privacy Policy

Terms & Condition

Confidentiality

HIPPA

“Dear friend, I pray that you may enjoy good health and that all may go well with you, even as your soul is getting along well.”

- 3 John 1:2 -

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