Sliding Scale Payment Form

At Victim 2 Victor Coaching, LLC we offer a sliding scale payment option for our weekly services to ensure that our services are accessible to individuals with varying financial resources. The following payment opytions are based on your income and ability to pay. Please select the payment tier that best represents your financial situation. 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. If there is a discrepancy, you will be asked to pay the difference prior to our meeting.

Todays Date

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Choose Weekly Option*

4 week - Full Price $3256 week - Full Price $525

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 - +: full price

Please upload proof of income (ie. recent paycheck stub, tax return; pdf, jpg, jpeg, gif, html)*

please make sure information uploaded is legible

Please select date and time for your first session. Subsequent sessions will be scheduled during first session

YOU MUST CLICK SUBMIT TO SUBMIT FORM