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.

Other
If none of the rates fit your current situation, what amount under $30 do you feel is sustainable for you? Leave blank if not applicable.
Please tell us anything you would like us to know about your current financial situation.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 and email of the individual you are splitting the payment with?
Please indicate whether you live in the following Zip Codes. You may be eligible to partake in our Verdant Grant. Briar (98036), Edmonds (98020, 98026), Lynnwood (98036, 98037, 98087), Mountlake Terrace (98043), Woodway (98020), Bothell (98011, 98012)
After submitting this form:
- After your first visit, our goal is to send you a bill via Quickbooks within the week based on the tier you selected.
- This will be sent to you as an email that you can pay directly online.
- You will receive a receipt after we charge your payment method
Why Session Payments are Important
- Inside Health Institute is a non-profit, and we rely on grants and any income from sessions to stay operational and open.
- Keep costs lower for everyone
- Focus our time on care, not billing logistics
If you are receiving sercives less than $30/session, you may be required to fill out an additional Payment Tier Form within a year to update your form.

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 for billing support: 📞 206-434-9561 ✉️ kimberley@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.
Signature
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IHI Counseling Payment Form

Payment Tier Selection/Billing Information