Counseling Assistance Application

Counseling Assistance Application

Please note that we do not adjust the cost of initial appointments/intakes. If you have questions about this form please contact your therapist or our administrative team at change@nichange.com.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your total monthly household income? This includes wages, social security, unemployment benefits, and any other sources for you and any other adult in the household.*
Total expenses: (please complete all blanks, enter "0" if not applicable)
rent/mortgage: blanks*
child support/child care: blank*
transportation: blank*
utilities: blank*
other (specify):
How many other adults (persons over 18 years old) live in your household?*
How many children live in your household?*
This application will not be considered without a paystub/w4 from within the last 3 months or proof of receipt of federal/state benefits. If you have a hard time uploading this document, you can email a copy to dianekeeling@nichange.com.

Cancelof
By signing below I confirm that the information above is accurate. I understand that I will be required to pay the full rate if this information is found to be untrue.*

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