Sliding Scale Fee Application

Psychotherapy Assistance Application

Please fill out this form if you would like to apply for a sliding scale fee for psychotherapy at Hagan Health. Our standard fee for psychotherapy is $100. Please note that applying for a reduced fee does not guarantee that the application will be approved. Our Director of Psychotherapy will review the form and someone from our office will be in touch within 24-48 business hours. Thank you so much for reaching out to us!

Client Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Email address

example@example.com

1. Please provide a brief overview of what you would like to work on in therapy.

2. Do you have a therapist preference? (Please note that the sliding scale only applies to Ben Hoffiman and Suzanne Lancaster at this time.)

3. Do you have insurance? If so, what type?

4. What is your approximate gross household income? How many dependents do you claim?

5. How often would you like to be seen? (once a week, every other week, etc.)

6. Would you like to provide any additional background information?

Please attach the most recent household tax documents, and someone from our office will reach out to you in approximately 24 to 48 business hours.