IHI Counseling Payment Form

IHI Counseling Payment Form

Please choose the option that best suits your needs
Payment Tier Selection/Billing Information

At Inside Health Institute, we believe whole-person care should be accessible to everyone. We use a simple, honor-based payment tier system to keep care accessible for everyone. We don’t bill insurance, as insurance often creates barriers to timely, personalized care. Please select the payment tier that best reflects your current circumstances. There is no income verification, and you may adjust your tier at any time if your situation changes—life happens.Those who are able to pay at higher tiers help make care available to others, supporting dignity, access, and community care. Our lowest tier for counseling is $30 per session, which covers the basic cost of providing services.
Please select the fee you’re comfortable paying for counseling.*

$85 Individual / $100 Couples or FamilyI can comfortably meet my basic needs. My finances are stable, and I have adequate savings. I’m able to pay at this rate so others can access care at a lower cost.$65 Individual / $80 Couples or FamilyI can meet my basic needs, and paying for therapy is not a financial hardship right now. My finances are generally stable, though they may fluctuate. I have some savings.$45 Individual / $60 Couples or FamilyMy basic needs are usually met, but not always guaranteed. Paying for therapy may sometimes be a financial strain. My finances fluctuate, and I have limited savings.$30 Individual / $40 Couples or FamilyI’m experiencing financial hardship, and my basic needs are not consistently being met.I am an Open Path Collective client and would like to use the Open Path Collective rate.None of these rates fit my current situation, and I’d like to talk about other payment options.Other
Please tell us anything you would like us to know about your current financial challenges.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
If you are completing this form for a child or other dependent, what is the name of the client who will be receiving counseling?
If you are seeking couples or family counseling, what is the name of the individual(s) joining you?
If you are seeking couples or family counseling, are you splitting the payment (Yes/No)? If so, what is the name of the individual you are splitting the payment with?
After submitting this form:
- You will receive a $1.00 invoice from Stripe by email
- You’ll be asked to add and save a payment method securely
- This allows us to bill you after each visit, based on the tier you selected
- Your card will be charged within one week of each appointment
What Happens Next

The $1.00 charge is a one-time verification and will be applied to your next visit.

Why We Do This

Saving a payment method helps us:
- Reduce administrative follow-up
- Keep costs lower for everyone
- Focus our time on care, not billing logistics
Your payment information is encrypted and securely stored by Stripe. We never see or store your full card details.

If your financial situation changes, your tier can be adjusted at any time.

An IHI staff member may contact you if we need to confirm or update your payment information.

Questions or billing support: 📞 425-256-2125 ✉️ info@insidehealthinstitute.org

Cancellation & No-Show Policy
- After two no-shows or cancellations with less than 24 hours’ notice, we may charge a $10 fee, regardless of your session rate.
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IHI Counseling Payment Form

Payment Tier Selection/Billing Information