Making Therapy Financially Accessible

Making Therapy Financially Accessible
Bridge Family Therapy aims to limit financial barriers to service. This confidential form helps us determine appropriate fee reductions based on financial need. Your information will only be reviewed by our financial coordinator and will not be shared with your therapist.

Your privacy matters to us. This form is HIPAA compliant, and your information is protected and accessible only to authorized staff for the purpose of determining your fee. Your financial information is automatically deleted after the fee determination process is complete and is not stored long-term.
Email Address*
example@example.com
Full Name*
Please select the therapist(s) you work with*

Samantha BarnhartJessica CoxCarlisle BadingMikah JonesCullen MacDonaldBailey SerranoTyler SeaboltJulia WarrenTiffanie Reid
Please select your approximate annual household income range*

Under $18,000$18,000–$31,000$31,000–$50,000$50,000–$62,000Above $62,000
Number of people in household (including yourself)*
Number of dependents under 18*
Please check all circumstances that apply to your situation:*

Currently a studentUnemployed or experienced job loss within past 6 monthsMedical expenses exceeding 10% of annual incomeCurrently receiving government assistance (SNAP, Medicaid, etc.)Supporting dependents other than children (elderly parents, etc.)Student loan payments exceeding $300/monthOther significant financial hardship (please explain below)
If you selected 'Other significant financial hardship,' please briefly explain:
By submitting this form, I affirm that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used solely to determine an appropriate fee for therapy services.
Signature*

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