Apply for Direct Therapy Services

One of the basic missions of Nourish is to provide support for families of children who have feeding challenges. We do this by funding dietitian evaluations and ongoing support or direct feeding therapy (occupational therapy or speech therapy) or specialized equipment not otherwise covered by insurance. If a child needs these services, Nourish wants to help them happen! If your child, or a child you know, would benefit from therapy services, but the family cannot afford those services, Nourish can help. You may apply directly from our website.

Read First to Apply

Application

To apply for assistance with direct therapy services, please complete one of the following applications by either mailing an application directly to Nourish or completing the application online. In both applications, please note that you are submitting medical information and that Nourish will not distribute or share medical or personal information to any third parties.

Printable Application - Click Here

Para ver la solicitud en español, haga clic aquí

Online Application

Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian

First Name

Last Name

Email

Phone Number

(###)

###

####

Medical Diagnosis

How will this support further your child’s mealtime goals?

Race/Ethnicity

What services are you requesting?

Current Feeding Therapy Office

Does your child receive any of the following services?

AHCCCS

WIC

ALTCS

Does the child’s health care plan or another agency provide this service?

Yes

No

If your health insurance plan is not being utilized for this, please explain.

Who is the responsible party for the co-pay with current insurance?

First Name

Last Name

Is there a deductible?

Yes

No

My family can pay:

Specify if the amount is per visit, or in total

I agree to participate in a follow up survey to help Nourish better serve our community.

Yes

Yes, and I'm also willing to volunteer for Nourish!

Required Signature

I understand and accept the above requirements. All of the information I have provided in this application is accurate and is subject to verification by scholarship provider at its discretion. I understand that all information contained within the scholarship application will be held in the strictest of confidence. We respect your privacy, and assure you that none of the information you provide will go beyond the Nourish scholarship review committee. By signing below, I understand and agree to the current Nourish Scholarship Policy.