Welcome to the BCI Cares Family Assistance Program!

The BCI Cares Family Assistance Program was created to provide financial support for families to purchase necessary therapeutic materials to optimize your child’s outcomes. The amount of financial assistance will be based off of need from the information provided on the application. Families are able to apply for this program one time per year, and funds will be received on a one-time basis. All applications will be reviewed and a response will be received within 2-4 weeks.

To apply for the BCI Cares Family Assistance Program, please fill out the application form below. If you have any additional questions regarding this program, please email familyservices@behaviorchangeinstitute.com.

BCI Cares Family Assistance Program Application

Personal Information

Client’s Name:

DOB:

Parent/Guardian(s) Name(s) if Applicable:

Client’s Address:

Phone (Home):

Phone (Cell):

Family & Financial Information

Number of Individuals in the Household:

Number of Dependents:

Gross Annual Income:

Additional Income (i.e. SSI, SSDI, Retirement, etc):

Is the client being claimed on another person’s tax return? (circle one):
YesNo

*Please note: If client is claimed as a dependent on another person’s tax returns, income and expenses are based on those of the person claiming the client on his/her tax returns.

Please include any additional information, if any that should be considered. (describe below):

Next Steps

After completing this application, please submit. We will review your application and provide a response within 2 weeks.

I affirm that all information on this form is true and complete to the best of my knowledge.

Parent/Guardian Name:

Parent/Guardian Signature:

Date: