Assistance Financial | Leading Ladies Society

Financial Assistance Application

Every child deserves the opportunity to complete the care they need.

The Extended Treatment & Additional Session Support Program provides financial assistance to eligible families whose children require additional therapy or medical treatment sessions that are not covered by insurance.

This application is intended for parents or legal guardians seeking assistance to help complete a child's recommended treatment plan. Each application is carefully reviewed based on documented clinical need, available funding, and program eligibility.

Please complete the form below. All information submitted will be kept confidential and used solely for the purpose of evaluating your request.

PART 1: APPLICANT & PATIENT INFORMATION

Child’s (Patient's) Full Name:

Date of Birth:

Month

Day

Year

Age

Parent / Legal Guardian Name:

Relationship to Child:

Primary Phone:

Email Address:

Multi-line address

Country/Region

Address

City

Zip / Postal code

PART 2: TREATMENT & PROVIDER DETAILS

Type of Treatment: (e.g., Speech, Physical, Occupational, ABA, Mental Health Therapy, Medical Treatment)

Provider / Clinic Name:

Treating Specialist Name:

Clinic Contact Phone / Email:

PART 3: CLINICAL NEED FOR ADDITIONAL SESSIONS

Please attach a recommendation letter or clinical summary from your child's treating provider outlining why additional sessions are necessary.

Attach link here:

Number of initial treatment sessions completed to date:

Number of additional sessions recommended to complete treatment:

Estimated cost per additional session:

Briefly describe how these additional sessions will directly impact your child's recovery, development, or long-term progress:

Short answer

PART 4: ACKNOWLEDGMENT & AUTHORIZATION

By signing below, I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false information may result in the denial or revocation of financial assistance.

I hereby authorize the reviewing organization to contact the medical/therapy provider listed in Part 2 solely to verify the clinical need and cost of the requested additional sessions.

Type Your Full Legal Name That Will Served as Signature:

Parent / Legal Guardian Signature:

Date:

Therapist/Counselor Signature:

Date: