Free2Talk Financial Assistance Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the application in order that Free2Talk may determine whether the patient qualifies to receive financial support from Free2Talk (up to 80% of costs for up to 16 sessions) to offset the cost of mental health or speech therapy.

Such therapy will be provided by one of our qualified mental health or speech therapy partner providers. Free2Talk will provide directly to the provider 80% of the cost of treatment on a monthly basis for up to 16 sessions after Free2Talk receives the invoice(s) from the provider. The patient will pay the 20% of the cost directly to the provider within the time required.

Please allow us up to 2 weeks to review your application. We will then notify you of approval and outline next steps.

Only complete the application below and do not email Free2Talk any additional information.

If you have any questions, email us at: Free2TalkFund@gmail.com

Email *

What is the name of the parent/guardian? *

Name of patient? *

What is the age of patient? *

What is your home address? *

What is your phone number? *

Type of treatment you desire? *

Speech Therapy

Mental Health Therapy

Both (Speech and Mental Health Therapy)

What is the desired length of treatment? *

8 Weeks

12 Weeks

16 Weeks

Are you willing to have the patient receive treatment from a provider partnering with Free2Talk? *

Yes

Name of partner practice from which the patient would like to receive treatment.
*

What is your monthly income after taxes? *

What are your monthly expenses (i.e, mortgage/rent, utilities, food, transport, insurance, education)? *

What are your savings (not retirement) and assets?

Please describe any extenuating circumstances prompting you to apply for assistance. *

Do you have health insurance that will cover mental health treatment? *

Yes

Do not know

If yes, what is your annual deductible? *

How did you learn about Free2Talk? *

You acknowledge that you hold harmless Free2Talk with regard to all information submitted herein via this online application and that you give Free2Talk permission to share this information with Free2Talk's collaborating speech and mental health providers in order to secure treatment for the patient for whom the application is submitted.
*

I do

Is there anything else that we should know?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms