Financial Assistance Request Form
Please fill out the information below to start the process of requesting financial assistance for one or more of our programs. Once your application is received, someone from our office will contact you to discuss options and request any additional information that may be needed. If you need assistance with this form, please call the office at (203) 801-5254.
Applicant Information
Applicant Name
*
First Name
Last Name
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Data of Birth
*
-
Month
-
Day
Year
Date
Applicant E-mail
*
example@example.com
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you filling this out for your self?
*
Please Select
Yes
No, another adult
No, another minor
Submitter Name
First Name
Last Name
Submitter Email
example@example.com
Submitter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate the services you are looking into
*
Occupational Therapy
Physical Therapy
Speech Therapy
Psychotherapy
Group Therapy
Wellness Horsemanship
What is your ability to pay?
*
Please explain why the cost of the sessions will create a financial hardship.
*
Please explain why you or your child will benefit from these therapy sessions.
*
Submit
Should be Empty: