Request for Sliding Scale

Request for Sliding Scale

We want to get you the help you need when you need it. Please provide some basic information to see what therapy rate you qualify for.
Below is a list of therapists we have who are accepting new clients and who offer a reduced rate and a sliding scale based on income for self-pay clients.*

Haylee O'Hara is a Provisional Licensed Marriage and Family Therapist who works with ages 3+ and offers individual, couples and family counseling.Laura May is a Supervised Marriage and Family Therapist who works with ages 12+ and offers individual, couples and family counseling.
Annual Household Income*
Please enter the ADJUSTED GROSS INCOME for all contributing household members from your previous years taxes. If you feel this is not an accurate reflection of your current situation, you may use current paycheck stubs to reflect your current estimated annual household income. Verification of this information may be requested.
Family Size*
Including yourself and your spouse, total number of dependents you are responsible for. (See # of exemptions claimed on taxes)
If you feel last year's taxes do not accurately reflect your current situation or pay, please describe any changes in circumstances or pay below.

Sliding Scale Rate
Based on the information you reported, you qualify for the $80.00 self-pay rate if you are seeing Supervised or Provisional Licensed Therapist. This is a 47% discount off of Norcon Family Counseling's base rate of $150.00 per session.
Based on the information you reported, you qualify for the $90.00 self-pay rate if you are seeing Supervised or Provisional Licensed Therapist. This is a 40% discount off of Norcon Family Counseling's base rate of $150.00 per session.
Based on the information you reported, you qualifty for a $100.00 self-pay rate if you are seeing Supervised or Provisional Licensed Therapist. This is a 35% discount off of Norcon Family Counseling base rate of $150.00 per session.
Based on the information you reported, you qualify for a $110.00 self-pay rate if you are seeing Supervised or Provisional Licensed Therapist. This is a 30% discount off of Norcon Family Counseling base rate of $150 per session.
Based on the information you reported, you qualify for a $120.00 self-pay rate if you are seeing Supervised or Provisional Licensed Therapist. This is a 20% discount off of Norcon Family Counseling base rate of $150.00 per session.
Based on the information you reported, you do not qualify for an additional discount at this time. Our self-pay rate is $150.00 per session.
To receive the above discount, please hit next and submit the brief contact information form.
Contact Information
To meet with this therapist you must meet the following qualifications. If you do NOT meet these qualifications, we do not currently have a therapist offering a sliding scale who is available to work with you. Please try back again at a later time.*

Client is 15 years or olderClient is seeking individual therapy (not couples or family therapy)Client does not meet these qualifications, but has received a special exception from the therapist.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Name of client if different from Contact Above

First NameLast Name
Statement of Accuracy*

I certify (promise) that all information on this application is true and that ALL household income is reported. I understand that Norcon Family Counseling will receive the information I have provided. I understand that Norcon Family Counseling has the right to require additional information such as paycheck stubs and/or the previous year's tax's return to verify the income and family size reported. I understand that if I purposely give false information, I will lose future discounts and be responsible for any past amounts that should have been charged based on the correct information.
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Request for Sliding Scale

Sliding Scale Rate

Contact Information