Sliding fee discount will be determined by the following table which is based on family size and annual income.

Once the

discount is determined by a client’s annual income and family size, the sliding scale fee will be determined by multiplying it by Aspire’s treatment charge rates as follows:

Initial Diagnostic Evaluation	$150.00
Initial Psychiatric/Medication Evaluation	$200.00
Psychiatric Follow-Up/Med Review/Therapy	$160.00
Psychiatric Follow-Up (med management)	$100.00
Individual Therapy	$100.00
Intensive Outpatient Therapy (per day)	$155.00
Day Treatment (per day)	$125.00
PRP Rehabilitation Assessment	$85.00
On/Off Site PRP Services (per month)	$475.00
Couples or Family Therapy	$125.00
Group Therapy	$50.00
Phone Consultation (15-20 minutes)	$25.00
Charge for Letters or Reports (less than 5 pages)	$20.00
Psychiatric Charge for Letters or Reports	$50.00
Fee for Missed Appointment (without 24-hours notice):
Therapy	$50.00
Med Appointment	$100.00
Service Fee for Returned Check	$40.00

(i.e. 60% discount multiplied by individual therapy fee of $100 equals a sliding scale fee of $40)

It is important to give at least 24 hours’ notice to cancel an appointment. If you do not you will be responsible for the missed appointment fee as determined by your sliding fee discount.

Payment is due at the beginning of the time of service. There are no exceptions. Aspire accepts cash or checks; credit cards are not accepted at this time.

The sliding scale fee will be re-determined annually.

I understand that I must bring current documentation at the point of re-certification of my sliding scale fee.

I have read the financial sliding scale agreement and I agree to its terms.

I understand that I may request a copy of this agreement.

I understand that my payment is required at the time of services in order to engage in treatment and I agree to pay the fees for the services listed above.

I also agree that upon termination of my services, any remaining balance must be paid to Aspire Wellness Center.

Client or Parent/Guardian Signature

Name

First NameLast Name

Aspire Wellness Center

Sliding Scale Fee Discount Application

It is the policy of Aspire Wellness Center, Inc., to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for a discount. The discount will apply to all services received at this clinic, but not those services or equipment that are purchased from outside, including reference laboratory testing, drugs, and other such services. This form must be completed every 12 months or if your financial situation changes.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

List all household members (Self, Spouse, Dependents, Other)

Annual Household Income

	Self	Spouse	Other	TOTAL
Gross Wages, salaries, tips etc
Income for business, self employment, and dependents
Unemployment compensation, worker's compensation, social security, supplemental Security Income, Public Assistance, verterans payments, survivor benefits, pension or retirement income
Interest, Dividends, Rents, Royalities, Income from Estates, Trusts, Educational Assistance, Alimony, Child Support, Assistance from outside the household, Other miscellaneous sources

I certify that the family size and income information shown above is correct.

Anything else you would like us to know about your situation

Office Use only:

Approved Discount

Name of staff person that reviewed document

First NameLast Name

Signature

Directoral approval?

YESNO

Financial Sliding Scale Agreement

Aspire Wellness Center

Sliding Scale Fee Discount Application