Transitional Sliding Scale

Transitional Sliding Scale Application
At Victim 2 Victor Coaching, we are dedicated to empowering individuals transitioning from domestic violence shelters to reclaim their strength and independence. Our specialized coaching services focus on supporting survivors of narcissistic abuse, providing a compassionate and personalized approach to recovery.

This application is designed to help us understand your unique circumstances and tailor our services to best meet your needs.

Confidentiality Notice: All information provided in this application will be kept confidential and used solely to determine eligibility for services and tailor our support to your needs.

We are here to support you on your journey from victim to victor, and we look forward to being a part of your healing process.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of contact

CallTextEmail
Are you currently residing in a shelter or transitional housing?

YesNo
Thank you for applying to our transitional sliding scale program at Victim 2 Victor Coaching. After reviewing your application, we found that you do not meet the eligibility criteria for this specific program. We understand this may be disappointing, but we are here to discuss other sliding scale and discounted options that might better suit your needs.
Name of shelter or transitional housing
How long have you been in your current living situation?
Expected Transition Date

MonthDayYear
Date
Were you referred to Victim 2 Victor Coaching by a shelter or support organization?

YesNo
If yes, please specify the name of the shelter or organization
if no, input n/a
What is your current monthly income, if any? (Include all sources of income)
How many people are in your household, including yourself?
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? (e.g., medical bills, student loans)
Based on your current financial situation, what amount do you feel comfortable paying per session?
What are your primary goals for seeking coaching services during this transition?
Do you have access to other forms of support or resources (e.g., family, friends, community services)?
Are you able to provide any documentation to verify your current living situation or financial status if needed? (e.g., shelter residency letter)

YesNo
Please upload documentation to verify your current living situation and/or financial status (ie. shelter residency letter, recent paycheck stub, tax return; pdf, jpg, jpeg, gif, html)*

please make sure information uploaded is legible
Cancelof
Do you agree to keep all information shared in this application confidential and understand that it will only be used to determine your eligibility for services?

YesNo
Signature*

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Transitional Sliding Scale Application