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Financial Assistance Application
Submission of a sliding scale request does not guarantee approval. Financial documentation is required, and by applying, you confirm that all information provided is accurate and complete. Sliding Scale Application Criteria and Guidelines Sliding scale applications are evaluated on an individual basis, taking into consideration factors such as household size, household income, recent changes in financial circumstances (including job loss), gaps in insurance coverage, and the need for continued care with a current provider. Applications are reviewed within 7 business days of submission. If approved, patients are offered a reduced rate of $100 per therapy session for up to 12 sessions. Patients must reapply before using their 12 approved sessions to be considered for continued sliding scale assistance. Approval is not automatic, and continued eligibility will be determined based on the information provided in the new application. Please note that superbills are not provided for sessions billed at the approved sliding scale rate. It is the patient's responsibility to ensure their application remains current and to submit a new application before their approved sessions are exhausted if they wish to continue receiving reduced-rate services.Our goal is to help patients maintain access to necessary care during times of financial hardship.
Patient Information
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Therapist Name
*
Annual Household Income
*
Household Size
*
Please Select
1
2
3
4
5
6
7
8
9
10
Change in Financial Status
*
Please Select
Recent Job loss
Recent reduction in pay/hours
Separation from partner/spouse
Unexpected medical expenses
Death in the family
New disability or illness
Business Closure or loss
Divorce Proceedings
Reason for Request
*
Sign Form
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitter Name (if different from patient)
First Name
Last Name
Continue
Continue
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