Grant Must Be Requested for Intervention by a Licensed Mental Health Professional

Dear Parent, we want to thank you for taking the time to fill out our application and please know we very much wish we could give each family the support they request. As you know Raising Wildflowers is a newly established non-profit there for our own financial resources are limited at this time. We understand the need is great, in fact some of our board members are right there in the trenches with you and we know the financial strain it can take to provide our kids with needed supports. As time goes on and RW grows we hope to provide many more grants.

Grant must be requested for intervention by a licensed mental health professional

Application is open to all married, common law, and single parents of adoptedchildren

At this time RW has only one $500 grant available

Please mail us your application by March 1st

Processing of applications will take anywhere from 1-3 weeks depending on the amount we have to review

All applicants will be notified by RW on the outcome of our review

Applicants who receive a grant must wait six months before applying for another RW post placement grant

Applicants who do not receive a grant can apply again when we offer the next grant

If applying for a foster child your social worker will need to approve the intervention you are requesting and reason why government funding will not cover the specific support.

Please mail your application to:

Raising Wildflowers

Box 274

Athabasca, AB

T9S 2A3

Date______

Adoptive parent 1 name______date of birth______citizenship______

Adoptive parent 2 name______date of birth______citizenship______

Email address______Phone number______

Mailing address______

Parent 1 occupation______Employer______

Employer website______Length of employment______

Monthly net salary ______

Previous Occupation______Length of employment______

Parent 2 Occupation______Employer______

Employer website______Length of employment______

Monthly net salary______

Previous occupation______Length of employment______

Marital status

Married______Common law______Single______

Current dependents (clarify if child is adopted, bio, or if you are fostering )

Name______Age______Relationship______

Details Of ChildNeeding Support

Child’s name______Date of placement______

Agency name/or fostercare ______Domestic or International______

If International which country______

Known special needs______

Brief description of issues child is having ______

______

When did child/or family first start receiving professional intervention______

Please specify the following:

What professional intervention has the child already received(counselling, physiatrist, play therapy,

neurofeedback, EMDR ect)

Which ones if any are covered by provincial health, government care, provincial funding, or private benefits and the hourly cost of each session you pay for ______

Type of intervention grant is being requested for and cost (example. Art therapy at $90 an hour session)______

Provide a description of why you or both of you would like professional support for yourself(feeling stuck with behaviours of child, secondary trauma, anxiety, marriage struggles related to trauma parenting, want to equip yourself better to understand your child ect.)

______

Have you received professional support previously? (include when, what reasons, how long, and cost of each session) ______

______

What type of intervention are you requesting? Include cost per session (counselling, neurofeedback, ect)

______

Name of clinic and professional______

Website______

Phone number______

Email______

Mailing Address ______

Funds will be given to the professional providing the care. If we inform you that your application will be approved for funding, please let the professional know that we will be contacting them directly to arrange payment.

Finances

Household annual net income______

Total debt amount______

Total monthly debt repayment(not including vehicle loan)______

Total monthly vehicle expenses (loan payment, fuel, insurance) ______

Total monthly grocery expenses______

Total annual family extracurricular activity fees(including school fees) ______

Total monthly giving (church tithing, cause organizations ect) ______

Total household costs (heat, mortgage, rent, insurance, water, TVect)______

Chequing accounts______Savings accounts______

Available lines of credit______

Available credit cards ______

Investments (stocks, real estate other then home, ect)______

______

Have you received any financial assistance from family, friends, church, or other to help cover professional supports in the past. If yes please indicate how much. ______

______

Parent 1 Print Name Parent1 Signature

______

Parent 2 Print Name Parent 2 Sign Name

______

Tell us about your family

Please include a 2-4 page write up about your family by including information like the following.

-What does your day to day life look like -How does raising a trauma child affect others in your family - Do you as the parent struggle with secondary trauma or anxiety -Does anyone else in your family receive professional intervention - If not, would anyone else benefit from receiving support either alone or alongside the specific child -Do you get much understanding and support from your extended family/friends/church/work -Did a parent leave a job or cut back hours to be more available to your trauma child -Does a parent work extra hours to help cover costs of professional intervention - Does the child have behavioural issues at school or in public - Is safety of anyone in the home at risk - Has a parent had to take any medication to help with sleep, stress, or depression - What led you to fostering or adoption - Do you receive any respite or have babysitters you can use and how often- Have or Do you travel for your child to receive professional intervention and how far?

OPTIONAL- On a separate piece of paperplease answer the following questions best you can. These do not in any way affect your application but instead help our team get a better look at areas RW can encourage better supports for adoptive and foster families. In some cases with these questions we are able to research more resources for your family in your specific area or that address your families specific needs.

-How supportive/helpful do you find your agency or worker in addressing your child’s needs or finding your family resources?

-Do you feel your agency or fostercare pre-placement training prepared you for life after placement and your child’s needs?

-What kind of information or training do you wish you could have received before or soon after placement?

-Do you attend a church? If So, which denomination?

-If you attend a church, how supportive or understanding do you find them of your child’s needs

-Does your child receive supports in school?

-How accommodating/understanding has your child’s school been in regards to the unique needs related to adoption/fostercare/attachment/trauma?

-Are you a Transracial family? If so, does your child or family experience difficulties pertaining to race or culture?

-How long did your child sit on a wait list for a mental health professional under provincial health care?

-Have you/Do you wish there was some basic training for your extended family members & friends to help them better understand how your family was built and the unique needs of your children

-Did you receive or been offered further education after placement from your agency or government workers?

-What areas do you feel you received the least information on? (attachment, fasd, race ect)