Sliding Scale Fee Application
I understand that counselling fees may sometimes be a financial concern. A limited number of sliding scale fee arrangements may be available on a case-by-case basis. Please complete this short form if you would like to be considered. Submission of this form does not guarantee approval, and any approved rate will be communicated to you separately.
Applicant details
Name
First Name
Last Name
Email
example@example.com
Mobile Number
-
Country Code
Phone Number
Preferred service:
In-person
Online
Are you a new or existing client?
New
Existing
Financial circumstances
Current employment status
Full-time
Part-time
Self-employed
Student
Not currently employed
Retired
Approximate monthly personal income range
Below S$1,500
S$1,500–S$2,499
S$2,500–S$3,499
S$3,500–S$4,499
S$4,500 and above
Prefer not to say
Are there any current financial circumstances you would like me to consider?
Requested arrangement
What fee range would currently be manageable for you for a 60-minute session?
I prefer ranges, for example:
S$120–S$139
S$100–S$119
S$80–S$99
I am currently experiencing significant financial difficulty and would like to discuss whether further support may be available.
Reason for application
There is no need to provide detailed personal, medical or counselling information.
Please briefly share why you are requesting a sliding scale fee.
Privacy note
The information provided in this form will be used only to assess your request for a sliding scale fee and for related administrative communication.
I understand that sliding scale arrangements are subject to availability and approval.
Please verify that you are human
*
Submit
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