How Can We Help? 

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

I’m interested to receive help with... *

Please check the box(es) that best describe the category of your request.

Respite Care

ABA

Speech Therapy

Occupational Therapy

Equipment

Tools

Alternative Therapy (please elaborate in next question's response)

Other (please elaborate in next question's response)

Is the service, therapy, tool or equipment covered by your insurance? *

Covered by insurance

Not covered by insurance

If requested, would you be willing to give HCSNA permission to speak with your service provider regarding planned services or therapies, insurance coverage, invoices and receipts? *

Yes

No

HCSNA considers applicants for our own funding; however, we also partner with the Kimberly-Dixon fund and Lincoln's Lodge to connect applicants with a greater pool of resources. If we think you may be a fit for one of the following organizations to support your request, do you give HCSNA permission to share your application with them? *

Yes to Kimberly-Dixon Fund

Yes to Lincoln's Lodge