Betterment Financial Options Request Form

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Betterment Financial Options Request Form

We believe every child deserves access to high-quality speech therapy. If you're interested in flexible payment options or sliding scale support, please complete this brief form. A member of our team will follow up with personalized options that fit your family's needs.

Email *

Parent/Guardian Full Name
*

Email Address *

Phone Number *

Child’s First Name (Optional)

Child’s Age *

What are your main concerns regarding your child’s communication? *

Preferred Therapy Format *

In-person

Virtual

Open to both

Which of the following best describes your current needs? (select all that apply) *

I’m ready to pay full private rates

I would benefit from a flexible payment plan

I’d like to be considered for sliding scale support

I’m not sure — please send more information

Required

Additional Information or Questions

Send me a copy of my responses.

Submit

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