Application Form

You can download our application form: Grant_Application1 , or you can fill out the form below and we will be in touch with you as soon as we have reviewed your application. If you have any questions about the services that we will help with you can check our Frequently Asked Questions page, or you can go to our Contact Page and send an email or call us. Thank you.

Grant Application

Applicant's Name (required)

Date of birth (required)

Applicant's diagnosis (required)

Parent/Gardian Name (required)

Address (required)

Day Phone (required)

Cell Phone

Your Email (required)

For which type of therapy are you asking for assistance?
Speech TherapyOccupational TherapyPhysical TherapyApplied Behavior Analysis

Service Provider (required)

Provider's Telephone Number (required)

Provider's Address

Number of visits that are requested? (required)

Estimated Cost (required)

Have you already had an evaluation?


Reference Letters: Two professional reference letters (teacher, therapist, physician, social worker)(required)
file types: jpg, jpeg, png, pdf, doc

Therapy documentation(required)
Please provide one of the following – as applicable:
Physician prescription (if requesting assistance for payment for therapy evaluation)

Therapy Plan of Treatment (if requesting assistance with therapy visits and evaluation has already
been completed).
file types: jpg, jpeg, png, pdf, doc