• Bridge to Care Family Application (Pilot)

  • Before you begin

  • Bridge to Care is a scholarship program for children (birth through 18) who live in the Greater Grand Rapids area and face barriers to consistent speech-language therapy. Scholarships are paid directly to participating providers and must be used within 12 months of the award start date. Applications are reviewed two times per year (February and July).

    Bridge to Care serves children who reside in the Greater Grand Rapids area. Eligibility is determined by the child’s home address zip code. A child is eligible if the home zip code is included in the Bridge to Care approved zip code list. 

    Eligible zip codes: 49503, 49504, 49505, 49507, 49508, 49509, 49548, 49418, 49512, 49519

  • Section 1: Child and Parent/Guardian Information

  • Child date of birth:*
     - -
  • Format: (000) 000-0000.

  • Section 2: Pilot Site Selection

  • Bridge to Care is currently in a pilot phase with two clinic sites. Please select the site you are applying to.
  • Select one:*
  • Are you currently an established client at the selected pilot site?

  • Section 3: Insurance and Coverage

  • Primary payer type (select one):
  • Is the child currently enrolled in Medicaid?

  • Section 4: Diagnosis or Reason for Therapy (Required)

  • Section 5: Barriers to Access

  • Primary barrier (select one):*
  • Additional barriers (select all that apply):*

  • Section 6: Therapy Cost and Need (Required)

  • Are you currently receiving outpatient speech-language therapy at the selected pilot site?
  • If no: Are you trying to start treatment at the selected pilot site?
  • What is the support you are requesting from Bridge to Care over the next 12 months (select one):
  • If you do not receive Bridge to Care support, what will most likely happen to therapy within the next 60 days?
  • Optional upload (if available): estimate, billing statement, denial letter, or visit limit notice.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Section 7: Hardship Statement (Required)

  • Section 8: Required Documentation Uploads (Required)

  • These documents will be reviewed by Building Blocks Foundation's Bridge to Care scholarship committee to determine eligibility and award assistance.

  • Upload 1: Statement of need from family member or referral or written recommendation for speech-language therapy from a qualified source.

    Upload 2: Supporting documentation. 

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Section 9: Required Acknowledgements

  • Please review and check each statement before signing the application

  • Building Blocks Foundation, Inc does not discriminate on the basis of race, color, national origin, religion, sex, disability, age, or any other status protected by law.

  • Date:
     - -
  •  
  • Should be Empty: