Therapy Sliding Scale Form

Sliding Scale Therapy Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your your current occupation?*
Are you a Veteran?*
What is your current annual income?*
What is your current household income?*
How many children/dependents do you financially support?*
Do you pay child support? If so how much per month? (Mark N/A if you do not pay child support. *
Is there anything else that you think would be helpful for us to know in regards to your income or expenses?
Please upload your most current W2 tax return, pay check stub or other income statement. Please upload the income information for the person who will be financially responsible for your treatment.*

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Sliding Scale Therapy Form