Sliding Scale Questionnaire
Answer the following questions if you would like to utilize a sliding scale for services. Note that this means you are not using insurance. Your responses will remain confidential and will only be used to determine the cost of sessions. Please answer honestly so that I may allocate services fairly. Fees will be reassessed every 12 months, or as needed, due to changes in life circumstances. If you have questions or would prefer to discuss with me, please email me at jazmine@theblackestsheep.org.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
I don’t have health insurance.
*
True
False
Are you under 26, currently a student, recently graduated (within the last year), or starting school within the next 3 months?
*
Yes
No
Do you struggle to make the minimum payments on your bills/credit cards/loans?
*
Yes
No
Does your income support any other person besides yourself, including pets/ESA/service animals?
*
Yes
No
Are you within (not an ally of) the BIPOC, neurodivergent, disabled, fat, or LGBTQIA2S+ communities?
*
Yes
No
Are you unemployed or underemployed (working part-time or contractually without benefits)?
*
Yes
No
Submit
Should be Empty: