Pay What You Can Request Form

Are you a current or perspective client?

CurrentPerspective

Name*

First NameLast Name

E-mail*

example@example.com

Phone Number*

Area CodePhone Number

Reason for requesting a Pay What You Can rate, please be as descriptive as possible: *

What are you able to afford per session? Sessions are weekly or bi-weekly depending on need. We strongly believe in our clients having a financial investment in their treatment. We are unable to offer free sessions. Please put an amount that you could afford for sessions. *

Completion of this form is not a gurantee for a reduction in fees. Granting of a fee reduction does not require utilizing Counseling @ Center Point. If you do not schedule following approval of a fee reduction, you may have to complete another form once you are ready depending on the time from approval to scheduling. Center Point reserves the right to refuse requests for a reduction in fees. Know that fee reduction may not be permanent and Center Point wants to work with you to provide services that you can afford and we can afford to provide. You will not recieve a reciept of this submission due to HIPAA and privacy purposes. Please know that we have recieved your submission. We work to respond to all requests within 2 business days. If you have any questions, please feel free to reach out to use directly at counseling@centerpointga.org or via phone or text to (770) 421-5088