Sliding Scale Request Form
We offer a limited number of reduced-fee appointments based primarily on household income. Please complete this brief form so we can determine whether a sliding-scale appointment may be available. All information will be kept confidential. We may request documentation of income when needed.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of Therapy
*
Individual/Couples Therapy
Group Therapy
Client Status
*
New client
Current client
Annual Household Income: Please include income from people with whom you share finances, as well as regular financial support from family or others, if applicable.
*
Under $45,000
$45,000-$69,999
$70,000-$99,999
$100,000-$124,999
$125,000-$149,999
How many people are supported by this household income (including yourself)?
*
Insurance: Do you have out-of-network insurance benefits?
*
Yes
No
I'm not sure
Other Financial Circumstances: Are there other significant financial circumstances that are not reflected by your household income? If yes, please briefly explain.
Scheduling: Are you available for weekday daytime appointments between 10am–3pm?
*
Yes
No
Referral: Were you referred to this form by a therapist?
If yes, please provide their name:
Reduced fees are based on our sliding-scale guidelines, financial circumstances, clinical needs, and clinician availability. Submission does not guarantee a particular fee or appointment, and reduced-fee arrangements may be reviewed periodically. Clinicians offering reduced-fee appointments may vary in training and experience; all receive appropriate supervision and consultation.
SUBMIT
Should be Empty: