Sliding Scale KAP Therapy Form

Sliding Scale KAP Therapy Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you seeking treatment in Austin or San Antonio

AustinSan Antonio
What is your your current occupation? *
Do you have someone who can provide transportation to and from KAP appointments?*
Are you a Veteran?*
What is your current annual income?*
What is your current household income?*
How many children/dependents do you financially support?*
If you pay child support, how much per month? (put N/A if you do not pay child support.*
In addition to your regular income, do you have access to other substantial financial resources such as savings, investments, trusts, or financial support from family or others?*
Are you open to undergo Ketamine Assisted Psychotherapy in a 3 person group format?
Are you open to providing an honest review after you have completed treatment?
Is there anything else that you think would be helpful for us to know about your financial situation?
Income-based discounts are intended for individuals with limited financial resources. If this does not reflect your situation, we kindly ask that you consider paying the full fee so we can continue supporting clients in greater financial need. I certify that the information provided is accurate and reflects my current financial reality.*
Full Name
Please upload at least one of the following below : your most current tax return, most recent check stub, or both.

Please submit the income information of the person who will be responsible for the payment of your treatment.
Please upload your most current W2 tax return, last check stub, or other income statement.*

You can upload multiple documents here.
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Sliding Scale KAP Therapy Form

Please upload at least one of the following below : your most current tax return, most recent check stub, or both.