Financial Assistance Request Form

Please know that we want to be sure that assistance is available for all who need it. Therefore, financial assistance is available for people who cannot afford the regular purchase price of the SelfQuest® Software. If you feel that you cannot afford the retail purchase of SelfQuest®, please submit the form below.

If you want to purchase SelfQuest and cannot afford it, please apply for our Financial Assistance program.

On our financial assistance program, you can receive the entire program for $197.

Our customer service department will review your application for financial assistance and get back to you shortly.


Your Name (required)

Your Email (required)

City (required)



Number of Persons in the Household

Household Net Annual Income


Please enter the following code in the box below