Sliding Scale Request Form
Please complete the form below to help us understand your financial circumstances. All information will be kept confidential. We may request documentation to verify income.
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 Therapy
Couple Therapy
Group Therapy
Are you available for weekday daytime appointments (10am–4pm)?
*
Yes
No
Client Status
*
I'm a new client and unable to pay the full fee
I'm a current client and unable to pay the recent fee increase
I'm a current client and no longer able to pay the full fee
Do you have out-of-network insurance benefits?
*
Yes
No
I don't know
If yes, please describe your out-of-network benefits:
Annual Household Income
*
Please include all sources, including financial support from family if applicable. You may be asked to verify income with a pay stub or financial statement.
Reason for Request
*
What circumstances are contributing to your financial need? (e.g., reduced income, medical expenses, job loss, debt, etc.)
Maximum Fee You Can Pay Per Session
*
What circumstances are contributing to your financial need? (e.g., reduced income, medical expenses, job loss, debt, etc.)
Were you referred to this form by a therapist?
If yes, please provide their name:
SUBMIT
Should be Empty: