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The Salvation Army Children's Services HALO Project Application & Waitlist Form
Cost of the Program

An initial fee of $250 ($25/class) for Family Participation in the Trauma Education Classes is due with all completed applications. Upon completion of the full program (all 10 sessions and family therapy during the 10 week sessions) the family will be reimbursed half of their initial fee ($125). Insurance Payments are accepted for family therapy sessions with participating insurances. Families are responsible to pay insurance co-pays, if applicable. If the family’s insurance is not accepted, a private pay of $75 per session is required at each therapy session. Adoptive families may qualify for Post Adoption Services through SWAN to include possibly support group and respite services for adoptive children. Please complete all fields within the following form.

Home Address *

Date

- Month - Day Year
Date
Referred By:
Enter Name
Type of Insurance
Enter Insurance Type
Child's Age Range *
Child's Name

First Name Last Name
Child's Date of Birth

- Month - Day Year
Date
Child's Tee Shirt Size

Small Medium Large X Large 2X Large 3X Large Other option

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The Salvation Army Children's Services HALO Project Application & Waitlist Form