Reduced-Rate Discount Eligibility Form
I offer a 35% discounted rate on appointments to support clients experiencing financial hardship. Please complete this short form to help me understand your situation.
Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
1. Are you currently experiencing financial difficulty that makes paying the full appointment fee challenging?
*
Yes
No
2. Are you currently receiving any government benefits or financial support? (e.g., Universal Credit, Income Support, ESA, Pension Credit)
*
Yes
No
3. Have you recently experienced any of the following that affect your financial situation? (Select all that apply)
*
Job loss or reduced working hours
Health issues affecting your income
Increased financial responsibilities (e.g., childcare, debts)
Other
If you selected 'other' to question 3 above, please use the space below to provide further information.
*
If this question is not relevant for you, please type 'N/A'.
4. Please share any additional information about your financial situation that you think is important for me to know:
HOW IT WORKS:
If eligible, you will receive a 35% discount on your appointment fee.
Discounted appointments are limited each month and are offered on a first-come, first-served basis.
I will contact you shortly to confirm your eligibility for a discounted appointment.
SUBMIT
Should be Empty: