Applicant Information

Name(Required)
MM slash DD slash YYYY
Address(Required)

Representative

The person assisting in filling out the application(Required)
Address(Required)

SPELLING Therapy Provider

Provider Address(Required)
REACT has permission to contact this provider regarding the applicant’s treatment needs.(Required)
Applicant’s provider provided applicant information on HIIPA Rights and you agree to for them to share applicant’s AAC treatment needs.(Required)

Income

Testimony of Need

Goals and Objectives

MM slash DD slash YYYY
If a scholarship is granted, funds will be directed to the provider as reimbursement for services. If you have inquiries please contact Maija@REACTforHope.org.