SLIDING SCALE FORM
NAME
*
First Name
Last Name
PHONE NUMBER
*
Please enter a valid phone number.
EMAIL
*
example@example.com
Please choose one:
*
Individual Therapy
Couple Therapy
Group Therapy
Are you available weekday daytime hours (10am-4pm)?
*
Yes
No
Please choose one:
*
New client - unable to pay full fee
Current client - unable to pay fee increase
Current client - unable to pay full fee
Do you have out-of-network benefits?
*
Yes
No
I don't know
If Yes, describe your benefits.
Annual Income
*
Please include all sources of income, including family contributions. You may be asked to verify this income with a pay stub or financial statement.
Reasons why you are unable to pay the full fee:
*
Please provide any details that may help us understand your need or a lower fee,such as loss of income, medical expenses, significant debt, etc.
Maximum session fee you can pay:
*
Did a therapist refer you to this form? If so who?
SUBMIT
Should be Empty: