SS Eligibility

Sliding Scale Eligibility Application

Please complete the form below to help us determine the appropriate fee for your sessions based on our sliding scale system.

If you are using insurance to pay for services, you do not qualify for sliding scale rates. Please exit this form.

How Our Sliding Scale Works:

Our sliding scale is designed to make therapy more affordable based on your annual income and dependent status. Rates can start as low as $75 per 60-minute session for those who qualify. Additional reduced rates may be offered on a limited basis and are subject to availability.

We do not offer 30-minute or 45-minute sessions for sliding scale rates.

How We Determine Your Rate:

✅ Your gross annual income.

✅ The number of dependents you financially support.

Sliding scale rates are available only for 60-minute sessions. Proof of income is required to verify eligibility. If you cannot submit the appropriate paperwork we will be unable to process your application.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please select one of the following to explain your low income status.*

Employed (full-time)Employed (part-time)UnemployedStudentRetiredSelf-Employed/Free LancerSeasonal WorkerDisabled (not working)Primary Caregiver (unpaid)Other
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 your most recent tax return here:*

Cancelof
Please upload your pay stubs for the last two months here:

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Please verify that you are human*
Sliding Scale Renewal & Visit Limits

If approved, your sliding scale rate is valid for six (6) months from the approval date. To continue receiving reduced rates after that time, you must complete a new application and submit updated proof of income.

Sliding scale rates apply to a maximum of two (2) therapy sessions per 30 calendar days. Any additional sessions during that time will be billed at the standard self-pay rate.

Approval does not guarantee continued eligibility beyond the six-month period and may change based on updated financial information, availability, or program capacity.

Submission of this form does not guarantee approval. We reserve the right to modify or discontinue sliding scale rates based on eligibility, documentation, and program availability. Sliding scale spots are limited, and we reserve the right to approve or deny applications based on eligibility, documentation, and current availability. Rates may be reviewed and adjusted if financial circumstances change or documentation cannot be maintained.
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.
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Sliding Scale Eligibility Application

How Our Sliding Scale Works:

How We Determine Your Rate: