FLOURISH-Provider Reimbursement Request Name Email Please enter a valid email address. If this is your first time submitting a reimbursement request to The Scholarship Foundation of St. Louis, please upload a completed W-9 form for you or your organization. Please know that we cannot mail reimbursements until we have one on file. If you need a blank W-9, you may download one here. Please enter the client's 4-digit FLOURISH ID (provided by the Scholarship Foundation): FLOURISH- Service(s) Provided: Date of Service Service provided:Please select... 45-minute session ($63.00) 60-minute session ($92.00) Amount Requested: $ Service provided:Please select... 45-minute session ($100.00) 60-minute session ($150.00) Amount Requested: $ Total Amount Requested: $ Payment Address: Name Please enter the name to which payment should be made. This may be your name, or the name of your office or practice. Street City State Zip Are you a bot?Yes
