Fee Waiver Application

Please complete this application if you are experiencing financial hardship and cannot afford our services. We carefully consider each application and look forward to hearing from you.

Name

First Name

Last Name

What services are you interested in?

1-on-1 Therapy

Group Therapy

Social Interaction

Financial Declaration

Please explain your financial need and basis for your fee-waiver request. Details help us to know how to prioritize these requests and whom we can best serve.

Fee Waiver Application

The Boxy Foundation

Location

Contact