Application Form

Mr. Strong Foundation grant application, we are only accepting grant apps from Pinellas, Hillsborough, Pasco, and Manatee counties (no out of state applications will be considered) from Oct 1st-Dec 31st, 2019 and we will notify you by Jan 13th, 2020 if we are able to grant funding for therapy services.

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