Self-Pay Discount Application

Qualifying patients can get started for as little as $50 per session. This short form takes about two minutes and helps us find the best possible rate for your situation. This form will allow us to place you in our sliding scale program or assign you a discount for therapy services.

There is no obligation to proceed and everything you share is kept strictly confidential. Once submitted, a team member will reach out with your personalized rate before your first appointment.

By submitting this application, I confirm that I do not have active health insurance coverage that includes mental health benefits applicable to services provided by Your Choice Mental Health Therapy, PLLC — OR — that I have insurance but am voluntarily choosing to pay out of pocket and will not submit claims to any insurance carrier with whom Your Choice Mental Health Therapy, PLLC has an active in-network participation agreement for sessions billed under this program.

I attest that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility and may result in retroactive adjustment of any reduced rate previously received.

Submission of this application does not guarantee approval or a specific rate. If approved, a formal rate agreement will be sent to me through my SimplePractice client portal for review and signature before any reduced rate takes effect.

I agree not to seek reimbursement from any insurance carrier with whom Your Choice Mental Health Therapy, PLLC has an active in-network participation agreement for sessions billed under this program.

Reduced-rate slots are limited and subject to availability. Your Choice Mental Health Therapy, PLLC reserves the right to approve or deny applications based on eligibility, documentation, and current program capacity.