Student Loan Repayment Program Application

Counseling and Wellness Center at CCPC

Program Overview

A bilingual, Spanish-speaking licensed (or candidate for licensure) behavioral health provider working at the Counseling and Wellness Center at CCPC can receive funding to repay qualifying educational loans. Participant must see underserved patients through CCPC’s Scholarship Fund.

Please review CCPC's Student Loan Repayment Program's requirements before submitting an application.

Program Requirements

This program has been generously funded by the 4Girls Foundation.

Important: Work Status at CCPC

At the same time that you complete the CCPC Loan Repayment Application below, you must also have applied to work as a Mental Health Therapist at the Counseling and Wellness Center at the Christian Center of Park City.

Mental Health Therapist Application

The following loans are NOT ELIGIBLE for the Student Loan Repayment Program:

Loans that were consolidated with any other type of debt or another person’s debt
HRSA Primary Care Loans
Parent PLUS Loans
Loans from a friend or family member

You MUST be able to offer clinical services in English AND Spanish to qualify for CCPC's Student Loan Repayment Program.

Student Loan Repayment Program Application

"*" indicates required fields

Name*

First Last

Email*

Phone*

Select Your License*

Eligible student loans through the CCPC Loan Repayment Program include only behavioral health-related programs leading to your current license.

Select the type of loan you are trying to repay.*

*Type of License

Do you currently receive any other loan repayment assistance?*

Some loan repayment programs do not allow participants to have other service obligations while under contract with them. By applying to this program, you assume the responsibility for ensuring that applying to CCPC’s Loan Repayment Program will not jeopardize your eligibility for other financial assistance or result in any negative action against you and release CCPC of any associated liability. CCPC aims to support local licensed therapists, and thus, will not disqualify applicants based on receiving other loan repayment assistance programs.

Yes

Loan Service Provider Information

What is your student loan balance as of the date of this application?*

Please indicate your monthly student loan payment amount.*

What is the payment due day?*

This is the payment date when you should receive the check.

Please indicate your loan provider.*

Loan Provider's Phone Number*

Loan Provider's Address*

Street Address Address Line 2 City State ZIP Code

Clinical Information

Are you able to offer clinical services in a language other than English? (Spanish and English are required.)*

Yes

Are you able to work full time or part time?*

Full time: 40 hours per week, year round

Part time: 20 hours per week, year round

If so, which language(s)?

NOT ELIGIBLE NOTICE. Do not qualify!

Have you already applied for the Mental Health Therapist job opening at CCPC?*

Mental Health Therapist Application

Yes

In order to fully complete CCPC’s Loan Repayment Program application, you must also apply for this position. Applicant can still proceed with this application.

Please describe the ethnic, cultural, and socioeconomic makeup of the patients you serve.*

Please describe how you would incorporate a Christian worldview into therapy, if the client requests to do so?*

Please list any additional training or certifications you have received (EMDR, DBT, CBT, Love and Logic, etc.).*

How many hours, if any, have you completed towards licensure status? (Only applies if you are not fully licensed; write N/A if you are fully licensed.)*

Documentation Uploads

License or Proof of Candidate Licensure Status*

Max. file size: 256 MB.

Proof of Loan*

Max. file size: 256 MB.

Application Notice

A complete provider application will be reviewed within 30 days. CCPC will contact you with additional questions. As this is a grant-funded program, you may be required to answer additional questions from the donor. This Loan Repayment Program is only awarded to one individual on an annual basis. By signing below, you are attesting that all statements contained in the application are true and accurate to the best of your knowledge. Any material false statement may disqualify you from participation in this and other CCPC programs. Should a materially false statement be discovered after an award is made, your contract may be in default. This application is meant to be completed concurrently with a job application for the Mental Health Therapist position. In order to be eligible for this program, you must agree to the following statements. Check the box next to each of the following statements to indicate that you agree:

I agree that CCPC will not be held liable for any potential negative impact or loss of other financial assistance programs resulting from your application or receipt of the CCPC loan repayment program.*

I certify that I am able to provide direct client services in-person in Park City, Utah.*

I certify that I am able to provide direct client services in-person in Park City, Utah.

I certify that a portion of the services I provide are accessible to underserved members of the community, regardless of insurance, financial or immigration status, supported by CCPC’s Scholarship Fund.*

I certify that I am currently licensed, or have candidate licensure status, and I am registered with DOPL.*

I certify that I am currently licensed, or have candidate licensure status, and I am registered with DOPL.

I certify that this loan repayment assistance will be used to pay for student loans that are directly related to my licensure.*

I certify that this loan repayment assistance will be used to pay for student loans that are directly related to my licensure.

I agree to a service commitment of two years with the Counseling and Wellness Center at CCPC, which starts counting at the start of the program if fully licensed OR, if currently a licensure candidate. I understand that failure to complete five years of service may result in a requirement to pay the loan assistance back.*

I certify my understanding that completing this loan repayment program application is not the equivalent of a job offer. In order to receive loan repayment, if selected as this year’s winner, I must also have received a separate job offer as a Mental Health Therapist at CCPC.*

I agree to fulfill all hourly requirements of direct client service throughout the duration of my participation in the CCPC Loan Repayment Program.*

I agree to fulfill all hourly requirements of direct client service throughout the duration of my participation in the CCPC Loan Repayment Program.

I understand that I am only eligible for this assistance as long as I work in Summit County, Utah.*

I understand that I am only eligible for this assistance as long as I work in Summit County, Utah.

I understand and agree that I must continue to make my monthly payments as required by my lender. CCPC will not be held liable for any late payment fees or fines due to payments made after the payment due date.*

You are required to maintain all practice attributes that make you eligible to participate in the CCPC Loan Repayment Program while you are receiving the benefit. Failure to do so may constitute a breach of contract and cause your approval to be withdrawn.

Electronic Signature*

Type your full name to sign this application.

Date*

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.