Sliding Scale Application Form

Sliding Scale Application Form

For regular sliding scale and transitional weekly sessions
At Victim 2 Victor Coaching, LLC we offer a regular sliding scale and transitional sliding scale payment options for our 4-week weekly services to ensure that our services are accessible to individuals with varying financial resources. You will also be asked to provide a copy of a recent check stub or the latest tax return to confirm the annual income range, transitional documentation. If there is a discrepancy, you will be asked to pay the difference prior to our meeting.
Are you applying for regular sliding scale or transitional sliding scale?

RegularTransitional (you must currently reside in a shelter or transitional housing)
Sliding Scale Application
Todays Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of contact*

EmailCallText
Please select your annual income range below to determine your sliding scale tier.*

$0-$25,000$25,001 - $40,00040,001 - $60,000$60,001+
Transitional Sliding Scale Application
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name of shelter or transitional housing*
How long have you been in your current living situation?*
Expected transition date?*

MonthDayYear
Date
How long have you been in your current living situation?*
Were you referred to Victim 2 Victor Coaching by a shelter or support organization?

YesNo
Specify the name of the shelter or organization
What is your current employment status?

Employed Full TimeEmployed Part TimeUnemployedStudentOther
Do you have any significant financial obligations or debts that impact your ability to pay for services? (eg. medical bills, student loans, etc)
Based on your current financial situation, what amount do you feel comfortable paying for a session or sessions, if you are approved?
What are your primary goals for seeking coaching services during transition?
Do you have access to other forms of support or resources (ie family, friends, community services)?
Are you able to provide any documentation to verify your current living situation or financial status if needed? (eg shelter residency letter)

YesNo
How many people are in your household, including yourself?
Please upload proof of income (ie. recent paycheck stub, tax return; transitional letter, etc ; pdf, jpg, jpeg, gif, html)*

please make sure information uploaded is legible
Cancelof
Take Headshot (please make sure the photo is clear)*
Signature*

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Sliding Scale Application Form

Sliding Scale Application

Transitional Sliding Scale Application