SS Eligibility

Sliding Scale Eligibility Survey

Hello there! Please answer the following questions to the best of your ability. Your answers will help us determine the appropriate fee for your sessions based on our sliding scale system.
Name*

First NameLast Name
Please select one of the following to explain your low income status.*

Employed (full-time)Employed (part-time)UnemployedStudentRetiredOther
Annual Gross Income*
(Please enter your total income before taxes and deductions for the past year.)
How many dependents do you have?*
(Include anyone you're financially responsible for such as children, elderly parents, etc.)
Please upload a copy of your last year's tax return here:*

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Please upload a copy of your last TWO MONTHS' pay stubs here:

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Attestation of Accuracy

By submitting this form, I hereby attest that all information provided is true and accurate to the best of my knowledge. I understand that any false statements or misrepresentations may affect the fee structure offered to me.
Please verify that you are human*
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Sliding Scale Eligibility Survey