Sliding Scale Application

  • Sliding Scale Application

    We recognize that accessing mental health care can sometimes feel stressful, and financial circumstances can make it even more challenging. Requesting a reduced fee is a common and completely valid part of seeking support. This form helps us understand your needs so we can fairly consider a sliding scale rate for your sessions. Completing this form does NOT guarantee a reduced fee, but it allows us to work with you in a transparent and collaborative way. The discount will apply to all services received at this clinic, excluding Genesight testing and any other laboratory testing. Please provide as much information as you feel comfortable sharing. All information will remain confidential. If you have questions while filling out the form, feel free to ask our team for guidance. We're here to help! 

  • Client Information

  • Client's Date of Birth*
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  • Format: (000) 000-0000.

  • Income

  • Is this a single-income household?*
  • Employment & Income Information*

  • Proof of Income

    Please provide one of the following options, a W2 form, a month's worth of PayStubs, or a Social Security Statement. This can be emailed, mailed or a physical copy can be brought in and a copy will be made for our records. A Months worth of proof of income is required: - Get paid monthly = 1 Document - Get paid biweekly = 2 Documents - Get paid weekly = 4 Documents
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  • How has your proof of income information been submitted?*
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  • Medical Assistance & Insurance

  • Do you have any income? If you click "No" and you do not have any income you must apply for medical assistance before your application will be approved.*
  • If you have recently applied for Medical Assistance please specificy the date of your last application.
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  • Do you currently have health insurance that includes mental health benefits?*
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  • Financial Sliding Scale Chart

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  • *Based on 2026 Federal Poverty Levels

    https://aspe.hhs.gov/sites/default/files/documents/b1bfa16b20ae9b89d525bc35de7c1643/detailed-guidelines-2026.pdf

     

  • Once the sliding fee discount is determined by a client’s annual income and family size, the sliding scale fee will be determined by multiplying it by Aspire’s treatment charge rates and/or by your individual insurances’ allowed amount as follows:

  • Cost of Services

  •  

    1. 90791- Initial Diagnostic Evaluation $175.00


    2. 90792- Initial Psychiatric/Medication Evaluation $250.00


    3. 90836-90838 Psychiatric Follow Up/Med Review/Therapy $200.00


    4. 99211-99215 Psychiatric Follow-Up (medication management) $100.00


    5. 90832- Individual Therapy under 30 minutes $50.00


    6. 90834- Individual Therapy 31+ minutes $125.00


    7. S9480 Intensive Outpatient Treatment (Per Day) $175.00


    8.H0002 PRP Rehabilitation Assessment $100.00


    9. H2018 On/Off Site PRP Services (Per Month) $600.00


    10. 90846 Family Therapy w/o patient present $150.00


    11. 90847 Couple or Family Therapy $150.00


    12. 90853 Group Therapy $50.00


    13. Phone Consultation (between 15-20 min) $25.00


    14. Charge for Letters or Reports (<5 pages) $20.00


    15. Psychiatric Charge for Letters and Reports $50.00


    16. Fee for Missed Appointment (w/o 24 hrs. notice) $50.00 Therapy/$100.00 Dr/NP


    17. Service Fee for Returned Check $40.00 

    (i.e. 60% discount multiplied by individual therapy fee of $100 equals a sliding scale fee of $60)

     

    It is required that a notice of at least 24 hours is provided by the client before an appointment is cancelled. Failure to provide a 24-hour notice will leave the client responsible for the missed appointment fee as determined by your sliding fee discount.

     

     

     

  • Agreement & Acknowledgment

    We apprecaite your openess in sharing the information you have provided during your applciation.

  • Please review the following carefully: 

    • A limited number of sliding scale appointments are available. Approval of a reduced fee is based on financial need and practice availability and is not guaranteed. 
    • Reduced fee arrangements are reviewed every six (6) months to ensure they continue to reflect your current circumstances. You will be notified in advance when your review period is approaching so we can revisit your fee in a collaborative and transparent way. 
    • If your financial situation changes at any time, you agree to notify the practice so we can reassess your fee together. 
    • To support consistent and predictable billing, a valid cred, debit or HSA card must be securely maintained on file prior to the start of services. If this is not provided we cannot apply the discounted rate.  

     

    • The card on file may be used for session fees, late cancelations, no-shows or outstanding balances in accordance with the practice's financial policy. 

     

    • If the card on file becomes invalid or declines, you will be notified and asked to provide updated payment information/ Services may be temporarily paused until billing information is resolved. 

     

    • Sliding scale rates apply to scheduled therapy sessions only and do not automatically extend to letters, reports, court testimony or other non-session professional services. 
    • We rely on the accuracy of the information provided. Knowingly providing false or misleading information may result in reconsideration of the reduced fee arrangement. 
       
  • Date of Signature*
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  • Automatic Billing Setup (Credit Card Authorization)

  • Once your Sliding Scale Application has been received, we will send you an email with a fillable PDF form that sets up automatic billing. Your Sliding Scale Application will not be approved until automatic billing has been set up, unless you have a prior payment agreement that would exempt you from automatic billing.

     

     

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