Over The Moon Therapy Scholarship Request
Request for financial support for therapy services
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Email *
Parent First and Last Name *
Parent Contact Phone Number *
Ok to text this number? *
Parent Email Address *
Child First and Last Name *
Child's Date of Birth *
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Tell me a bit about why you feel like Occupational Therapy and or Speech Therapy  important for you and your family right now? What specific hopes or goals do you have for your time in therapy? *
My evaluation cost is $350. Typically I ask families to cover the cost of the evaluation and offer the discounted rates for ongoing services. Would this be possible? *
If you answered No above what is the Maximum you could pay for a therapy evaluation?
Please share some about your family's financial situation. Including any hardships or limitations that make it difficult to pay the full rate ($85/hour) for  Therapy treatment. *
I typically offer discounts for episodes of care that last 10 sessions. Knowing you will likely see me for 10 sessions at the rate we agree to, what do you feel you could contribute towards your child's occupational therapy treatment? Please note that I do not do any completely pro-bono services. I request that families make some financial contribution to services. *
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