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Financial Assistance

Submit the following form and a member of our team will be in touch with you shortly regarding receiving discounted or donated services.

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First Name

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Last Name

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Email

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Where do you live?

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Child’s Age

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Child’s Diagnosis (select all that apply)

Autism Spectrum Disorder (ASD) Deaf-Blindness Developmental Delay Emotional Disturbance Hearing Impairment (including Deafness) Intellectual Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment (OHI) Specific Learning Disability (SLD) Speech or Language Impairment Traumatic Brain Injury (TBI) Visual Impairment (including Blindness) Other

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If other, please specify:

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What services are you interested in learning more about? (select all that apply)

IEP One-Time Review BIP One-Time Review Ongoing Advocacy Financial Guidance Medical Recommendations Social Networking

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What is your household annual income?(required)

$0-$19,999

$20,000-$49,999

$50,000-$89,999

$90,000-$129,999

$130,000-$149,000

$150,000+

Prefer not to answer

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Is there anything else you’d like us to know at this time?

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