Free Application

free services application form

Complete the below form and we’ll get in touch as soon as possible!

personal information

Full name *

Date of birth

Gender

Primary contact number

Alternate contact number (optional)

Email address *

address

Street address

City

State

Zip code

Country

Dyspraxia details

Name of affected family member

Relation to applicant

Date of Dyspraxia diagnosis

Currently receiving any therapy or medical treatment?

If yes, please specify

financial information

*Note: This information will be kept confidential and will only be used to assess eligibility for free services.

Total annual family income

Number of family members in the household

Is the family receiving any form of financial assistance or benefits?

If yes, please specify

requested service type

Type of service

Preferred method of therapy

documentation

Proof of Dyspraxia diagnosis

Choose File

Proof of income (e.g., recent pay stub, tax return)

Choose File

additional information

How did you hear about our free services?

Please share any other relevant information or specific needs

terms and conditions

Thank you for applying for our free services. We will review your application and get back to you within 14 days.

There was an error trying to send your message. Please try again later.

make a difference

donate now