Grant Information Request Form

Please complete this form if you are interested in receiving information about grants available to fund speech or physical therapy. Providing accurate information allows us to better understand your needs and assist you in navigating the grant application process. Your responses will remain confidential. 

Note: Completion of this form does not guarantee eligibility for grants or immediate access to funding.

Email *
Parent/Guardian name
Child's First and Last Name
Phone number 
Email address
What is your preferred method of communication?
Clear selection
I am seeking funding assistance for:
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Has your child received a speech-language evaluation?
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Has your child received a physical therapy evaluation?
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What are your child's diagnoses? Include speech and medical diagnoses.
What is your annual household income? Note: Many grants will require that you submit a copy of your IRS 1040 form.
How many people live in your household?
How many children live in your household?
Do you have insurance?
Clear selection
Does your insurance cover speech therapy?
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Does your insurance cover physical therapy?
Clear selection
What questions do you have?
Submit
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