Sliding Scale:
Sliding Scale:
Income
Diagnostic Assessment
Follow Up Appointment
$150,000 +
$300
$200
$100,000
$300
$150
$75,000
$200
$125
Less than $50,000
$200
$100
**Medical cannabis certifications are $200 for everyone and recertifications are $150 for everyone not involved with consistent psychiatry appointments. Certifications and recertifications are free for any client who is involved with consistent psychiatry appointments and must have acceptable insurance (must agree to meet at least once monthly).**
1. I verbally reported my gross yearly income to the clinic as $
2. Based on the clinic's published sliding scale, I understand and agree to pay the following rates:
-Diagnostic Intake: $
-Follow-Up Session: $
-Other (if applicable): $
11. I understand that I am not required to provide proof of income. These fees are based solely on my self-reported income and my voluntary choice to self-pay. I understand that I may request to update my income information at any time if my financial situation changes.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Signature
Printed Name of Patient or Responsible Party
First Name
Last Name
Capacity of Responsible Party (e.g. parent, guardian, etc.)
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