Sliding Scale Fee Form

Sliding Scale Fee Form
Please fill out this form if one of these apply:
- you do not have insurance
- your insurance coverage is not currently accepted
This is a sliding scale/reduced fee application for those who need assistance and would like to pay outright for counseling services.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Income
Type of Income:

Regular EmploymentContractor/Self EmployedDisability (SSI/SSDI/VA)UnemployedOther
If employed, please list name of employer:
Household monthly income:
How many household members:
Life Circumstances
Why would you like reduced fee sessions?
Sliding Fee Determinations
Reduced fees are determined on a sliding scale based on your income, household size, and will be approved on a case by case basis. Reduced spots are limited and at the discretion of the therapist.

Fees are typically between $50-150 depending on this sliding scale. Once your application is reviewed, you will be contacted via email with our determination within 48 hours of submission. Thank you!
Should be Empty:

Income