Sliding Scale Income Verification Form

1
Sliding Scale Income Verification

Please upload income documents to verify your Sliding scale fee session quote.

Types of Documents that can be used:

IRS Form W-2

IRS 1099

Social Security Statement

Pay Stubs (Please include dates)
2
Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
4
Client ID Number(If Known)
If you are a new client you may not know this, that is okay please click next!
5
Documents Upload* This field is required.You can upload multiple documents
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
6
Other comments (Optional)
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: