Genesis PT & Wellness Scholarship Nomination Form
This is a form to nominate yourself or someone you know who would benefit from our Genesis Scholarship fund to be able to receive a discounted rate per visit. We believe that everyone should have access to the high quality of pelvic health care we provide here at Genesis PT & Wellness. We have created a scholarship fund for qualifying patients and clients to help bridge the gap, ease the financial burden, and increase access to care. 
If you feel that you, or the person you are nominating, meet the below criteria,  please answer the questions below and a member of our team will get back to you after we review. 

Qualifications
  • You, or the person you are nominating are in need of high quality pelvic health care to improve your quality of life
  • You, or the person you are nominating are unable or significantly limited in your ability to afford the full cost of care at Genesis PT & Wellness
  • You, or the person you are nominating are ready and willing to partner with us in your plan of care, attend each of your appointments outside of extenuating circumstances, and plan to remain compliant in your home exercise program and any other suggestions made by your therapist
  • You, or the person you are nominating understand that the plan of care is set by your therapist and they will make recommendations based on frequency of care as well as when to discharge you from care, based on your symptoms and progress
Email *
Name of person completing this form *
Name of person being nominated *
Email of person being nominated *
Phone number of the person being nominated *
How did you hear about this nomination form? *
If you or the person you are nominating are currently a patient at Genesis PT & Wellness, please let us know who your therapist is: *
Please tell us why you, or the person you are nominating would benefit from our scholarship fund. *
Please express any extenuating financial circumstances that are affecting the person you are nominating, that Genesis PT & Wellness needs to be aware of.  *
Which location or therapist are you, or the person being nominated, looking to work with? *
A copy of your responses will be emailed to the address you provided.
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