B & G Hope Grant Application Form
PERSONAL INFORMATION
All information is required*
Full Name
First Name
Middle Name
Last Name
E-mail
example@example.com
Phone Number
Birth Date
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Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Place of Employment
Primary Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you provide therapy services at a location or facility outside your primary place of employment?
If yes, please provide the location name, address, phone number, and employer's email address.
Proof of License
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REFERENCES
Please provide two client references.
Reference Name
First Name
Last Name
Reference Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Reference Name
First Name
Last Name
Reference Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
PROFESSIONAL BACKGROUND
What is your medical specialty or area of expertise?
Please provide a brief overview of your educational background and credentials.
How long have you been practicing in Southwest Louisiana?
How do you currently assess and treat children with motor delays or developmental challenges in your practice?
Have you received specialized training in pediatric therapy or developmental interventions? If yes, list them.
NISE E-STIM CERTIFICATION INFORMATION
Have you received any training for NISE E-STIM?
Please Select
Yes
No
If yes, please provide more detail?
What motivated you to seek training in NISE E-STIM?
How do you envision incorporating E-STIM into your current practice to benefit your patients?
ADDITIONAL INFORMATION
As a provider, do you accept clients on Medicaid?
Please provide any additional information or insights that you believe are relevant to support your application for this grant.
Do you understand that Participants are required to bring their own Chattanooga Continuum or EMPI Continuum e-stim unit along with their own electrodes?
Please Select
Yes
No
Signature
By signing this form, you are agreeing to allow Families for Inclusion to use your story, journey, and experience for our social media, website, and press releases.
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