SS Eligibility
  • Your Choice Mental Health Therapy
    Sliding Scale Fee Application

    Please complete the form below to help us determine the appropriate fee for your sessions. All information is kept confidential and used only to assess eligibility.

    If you have active health insurance coverage that includes mental health benefits applicable to services provided by Your Choice Mental Health Therapy, PLLC, 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 $55 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, 45-minute, or couples sessions at 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 documentation, we will be unable to process your application.
  • Format: (000) 000-0000.
  • Please select one of the following to explain your income status.*
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  • General Information

    Please read all of the information below before signing
  • Application Acknowledgment

    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 my current coverage does not extend to mental health services rendered by this practice.

    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 any reduced rate previously received.

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

    Sliding scale 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.

    Signature field follows below. Your electronic signature confirms that the information above is accurate and that you understand submission does not guarantee approval.
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