Please note this is for current clients ONLY!

To request funding please fill out the request form below.

This form is to be filled out by the recipient or the legal caregiver when requesting funds.

Conditions to requests:

• The request will be made at least two weeks after CBT receives this request form so, please plan accordingly, some exceptions will be made.
• If you were granted funding from the Community Impact Funds, you only can utilize the amount of funding which you were granted. Or if you were granted for a specific reason you need to only complete form to fulfill that request. Anything behind that will be denied.

Client Request Form

​I hereby agree that everything I have requested on this form is related to my medical condition. And that it is true and accurate to the best of my knowledge and that CBT is relying on this form being filled out accurately to make its decision to support the requested funding. I understand that this request can be rejected by CBT. Furthermore, I understand that CBT is not obligated to accept the request and I am entitled to an explanation of why it was denied.