Counseling Services

Although I accept clients of all ages, I work primarily with youth ages 5 - 18 working on concerns such trauma, family changes, grief and loss, anxiety, and depression. As a clinician I work from a place of 'with' and use a team approach to care. I provide resources, skills, tools, and help to parents and caregivers, work with teachers and school personnel, to provide youth with the support they need to see lasting change and growth. I do use a variety of interventions, most commonly Cognitive Behavioral Therapy, EMDR, or creative arts such as sand tray. - Dynisha Smith

Income guideline

We require the following documentation in addition to this fully completed application:

A copy of your most recent four weeks of paycheck stubs from each adult member in household who is working.

And, if applicable:

Documentation of SSI, SSD, food stamps, AFDC, unemployment, self employment income letter, student loans, financial aid, child support, foster care license (if filling out application for foster child), or any other documentation of monetary gain in this calendar year.

If homeless, please provide evidence from the homeless shelter in which you are currently residing.

If there are any extenuating circumstances that are out of the ordinary, please write a letter of explanation.

Please drop off or mail all documentation to the Club you are seeking services for.

Incomplete submissions will not be considered. Individuals who can be included in a family unit receiving financial assistance are only those claimed on current tax returns. Other individuals may apply separately. Consideration will be given to special or extenuating circumstances. Our goal is to take action on applications as quickly as possible.

Expect 2 weeks to process. Applications are approved in the order in which they are received while funds are available.

Scholarship Application

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Participant Name*
First Name Last Name
Participant's Race*
Does the participant identify as Hispanic?*
Financial Information
Are you currently employed?*
Name of Employer*
What income method currently fits you*
- Monthly Salary
- Hourly Wage
- Weekly Income
What is your Monthly Salary?*
What is your Hourly Wage?*
What is your Weekly Income?*
Do you have any other forms of income?*
(SSI, Child Support, Alimony, etc.)
Other forms of income*
Type Amount

Please add more rows if necessary
Household Information
Household size*
How many adults are in the household?*
How many dependent children are in the household?*
Other Information
Is your financial need the result of the Covid-19 Pandemic?*
Please let us know if there is anything else we should know
By agreeing, I certify this information is true and complete to the best of my knowledge.*
- I agree
I understand it is my responsibility to notify The Boys & Girls Clubs of Ada County regarding changes in my financial and/or membership status.*
- I understand
I understand and agree that The Boys & Girls Clubs of Ada County may make contacts to verify this information.*
- I understand and agree
I understand that my financial need may be re-evaluated at any time by the Boys & Girls Clubs of Ada County.*
- I understand
I authorize employers and/or other income sources to release financial information to the Boys & Girls Clubs of Ada County.*
- I authorize
I also understand that all information will remain confidential.*
- I understand
What is today's date*
MM slash DD slash YYYY
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Phone
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Type	Amount

Counseling Services

Scholarship Application

Personal Information

Financial Information

Household Information

Other Information