Oral Placement Therapy Scholarship Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To apply for an Oral Placement Therapy scholarship, please complete the application below. New families
need to view an introductory video to be eligible for an Oral Motor Therapy Scholarship (second video on the page 'As a Parent - SRJ': https://talktools.com/pages/parent-video-library.

After the application deadline you will receive notification from The FOUNDATION with instructions for scheduling your appointment including choice of dates and times.

Parent Information

First Name: *

Last Name: *

Address 1: *

Address 2:

City: *

State: *

Phone Number: *

Email: *

Applicant Information

Child's First Name: *

Child's Last Name: *

Age: *

Program Information

Does your child currently receive speech therapy? *

My child currently receive Speech Therapy.

My child does NOT currently receive Speech Therapy.

Has your child been evaluated by a Talk Tools Therapist? *

My child has had a Talk Tools eval in the past and I am requesting a follow-up appt with Jill.

My child has had a Talk Tools eval in the past and I am requesting a follow-up appt with Renee.

My child has had a Talk Tools eval in the past and I am requesting a follow-up appt with Whitney.

My child has never had a Talk Tools eval and I am requesting the initial evaluation. I am aware I need to watch the video "Parents' Guide to Talk Tools" which is the second video on this page: https://talktools.com/pages/parent-video-library and complete the questionairre.

If you are requesting a follow-up appointment, please provide the date of your last eval.

If you have had a previous evaluation please answer the following questions.

Please select the months you participated in a Skype Session: *

February

March

April

May

June

We are not currently participating in the Talk Tools program.

Required

What areas do you feel you need the most assistance with?

How many days per week on average are you able to work on any part of your program plan?

Which specific activities do you find easiest to implement?

Do you have a therapist assisting you in implementing this program plan?

Scholarship Amount

Please let us know the scholarship amount required. You can request any amount necessary for your family to participate in the clinic. It is not guaranteed you will receive the full amount requested. It is our goal to allow as many families as possible to participate so we will do our best to accommodate every need. Please take into consideration if you can afford to pay for a portion of your evaluation, that will allow another family the opportunity to participate.

I do not need a scholarship.

I need a partial scholarship.

Requested scholarship amount: *

Please not we do not give full scholarships for Oral Motor evaluations. If you do not need a scholarship please enter 0.

Other Information

Comments:

I am a member of The Foundation.

Required

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Down Syndrome Foundation Of Florida.