Sliding Scale Request / Fee Appeal
The scale is based on availability and financial need.
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
*
Select One:
*
Please Select
I am a new client and unable to pay the full fee.
I am a current client and unable to pay the fee increase.
I am a current client who is no longer able to pay their full fee.
Service:
*
Individual Therapy
EMDR Therapy
Couples Therapy
Group Therapy
Current Fee
What is the maximum fee you could pay per session?
Do you have out of network insurance? If so, what are your benefits?
Are you available during daytime hours (10am-5pm)? Are you available during weekends?
Annual Income (please include all sources of income, including family contributions). You may be asked to verify this income with a pay stub or financial statement.
Reasons why you are unable to pay the full fee. Please provide any details that may help us understand your need for a lower fee, such as loss of income, medical expenses, significant debt, etc..
Submit
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