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.

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:*

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Please upload your pay stubs for the last two months 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*
Should be Empty:

Sliding Scale Eligibility Application

How Our Sliding Scale Works:

How We Determine Your Rate: