Online Application

This application is for Aftercare only.

For information on funding for STICC's full program, please email information@savingteens.org

STICC Online Application for AFTERCARE Scholarships

Please fill every field. If a field does not apply to your situation, you may type n/a or 0 if a number is required.

The After Care Application requires detailed information.

You may find it helpful to print the application and gather the information prior to filling it out online.

Instructions for Completing the Application

1. Applicants must be the parent or legal guardian of the child in need of transitional assistance.

2. Provide the names, addresses, phone numbers of the therapeutic program that has been or will be soon completed, as well as the name and phone number of any current therapist/counselor. 

3. Provide the names, addresses and phone numbers of the proposed aftercare providers along with a description of the aftercare services and plan and the child’s and family’s commitment to the plan. 

4. Provide current financial data. STICC reserves the right to request further documentation of financial information to assess financial need.  

5. Please print and sign these Releases and Authorizations so that we may evaluate your application and discuss it with the references and providers you have listed.

6. Please fax the Releases and Authorizations plus a copy of your most recent Federal Tax Return to 617-344-8250, Attn. AFTERCARE

7. Please send the original signed Releases and Authorizations by mail to:

   Saving Teens In Crisis Collaborative
   Attn: AFTERCARE
   PO Box 441363
   W. Somerville, MA 02144

Applicant Name: *

Spouse Name: *

Name of Child Intended to be Assisted by Scholarship Funds: *

Relationship of Applicant to Child Seeking Aftercare: *

Applicant Address: *

City: *

State: *

Zip Code: *

Applicant Date of Birth: *

Marital Status: *

Email: *

Home Phone: *

Work Phone: *

Mobile Phone: *

Child's Date of Birth: *

Graduation Date: *

Please state the graduation date, or anticipated graduation date of your teen, as well as the name of the program.
** Please remember that your teen must have completed a full program to be eligible for an Aftercare Scholarship.

Amount of Funding Sought: *

1. Describe your child's current therapeutic program, current progress, and anticipated educational plans: *

2. Describe aftercare plans for your child (including child's and family's commitment to participate in aftercare): *

3. Explain why you believe the aftercare program you have chosen will assist your child's transition. Please also ask your current program therapist to fax or email their recommendations for followup treatment: *

4. Have you received assistance from any other sources? If so, please indicate the source(s) and amount(s): *

5. Please provide, to the extent possible, the names of references, including phone numbers, who may be contacted regarding your child’s history, progress in his/her current program, and commitment to continue with aftercare. It is understood that three independent references will not be possible to obtain in all circumstances.

Reference from previous school, past counselor, other knowledgeable adults outside family: *

Reference from current therapeutic program: *

Reference from expected future program, school, or counselor: *

6. STICC requests that you provide your teen's most recent Psychoeducational or Neuropsychological Test Results: *

Use this box to provide the dates of the most recent testing. If these results are not available, you may provide a treatment plan.
** Send these results to STICC via fax (617-344-8250) or by regular mail as soon as possible so that we may evaluate your application.

7. Please provide us with any other information you believe is important for STICC to assess your application for Scholarship funds: *

Applicant Financial Information

Number of Years at Present Address: *

Family Size (Include adults and other legal dependents): *

Employer(s): *

Description of Occupation(s): *

Business Address(es): *

Business Phone(s): *

Sources of Income (yourself, spouses and other dependents)

Income for Yourself

Salary, Wages and Tips: *

Self Employment Income: *

AMDC and Other Public Assistance: *

Alimony & Child Support Received: *

Other Pension Benefits: *

Unemployment/Workman's Comp: *

Rental Income: *

Other Income (Please describe): *

TOTAL INCOME (FOR YOURSELF): *

Income for Spouse and Other Dependents

Salary, Wages and Tips: *

Self Employment Income: *

AMDC and Other Public Assistance: *

Alimony & Child Support Received: *

Other Pension Benefits: *

Unemployment/Workman's Comp: *

Rental Income: *

Other Income (Please describe): *

TOTAL INCOME (FOR SPOUSE & OTHER DEPENDENTS): *

Your Assets (including spouse and other dependents)

Please provide Current Balance or Assessed Value ($)

Cash: *

Checking Accounts: *

Investments:

- Credit Union: *

- CDs: *

- Stocks/Bonds: *

- Other Investments: *

Retirement Accounts: *

Real Estate:

- Home: *

home - location/address: *

- Other Real Estate: *

other real estate - location/address: *

Vehicles: *

Other Assets: *

TOTAL ASSETS: *

Your Liabilities (including spouse and any other dependents)

Please provide Balances ($)

Mortgage Loans: *

Credit Union Loans: *

Bank Loans: *

Credit Cards: *

Other Liabilities: *

TOTAL LIABILITIES: *

Estimated Monthly Expenses (for yourself, spouse and other dependents)

Rent: *

Mortgage Payment: *

Auto Loan Payments: *

Other Loan Payments: *

Food: *

Clothing and Personal: *

Alimony or Child Support Paid: *

Insurance Premiums Paid: *

Contributions to Retirement Plans: *

Utilities: *

Other (please specify): *

TOTAL MONTHLY EXPENSES: *

Note: The application process cannot proceed without our receipt of the releases and authorization forms!

Please fax the Releases and Authorizations plus a copy of your most recent Federal Tax Return to 617-344-8250, Attn: AFTERCARE

Click here to download the STICC Releases and Authorizations.

Please send the original signed Releases and Authorizations by mail to:

Saving Teens In Crisis Collaborative

   Attn: AFTERCARE
   PO Box 441363
   W. Somerville, MA 02144

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