Sliding scale application

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We are all living through tumultuous times and many of us are feeling the pinch financially. Massage is one of the ways we can care for ourselves and each other. If cost has been a barrier, I hope this option helps you access the care that you deserve.

This form is meant to be used by folks who are in need of services, but are unable to pay our regular rates due to financial hardship.

We will use this form to fill our sliding scale appointments at Homebody Massage & Bodywork in Loveland CO, and will contact you to approve/correspond with regards to your request.

These appointments are first come first served.

I understand that filling out this form does not guarantee an appointment with Nicole. It will however warrant a response where I will be informed if my appointment can be accommodated or not. *

Yes, I understand

Full name/pronouns

Phone number

Email address

Choose your cost from the scale, use the graphic as a guide. *

$82.50 - jar 1

$77 - jar 2

$66 - jar 3

Which time do you prefer for your sliding scale appointment? *

3:00-4:00pm

4:30-5:30pm

6:00-7:00pm

Please mark all that apply *

Unhoused/housing insecure

Disabled

BIPOC

LGBTQ+

Single parent

Recent job loss

Student

Required

Please list any disability accommodations you might need. (ie. noise level, smells, masking) Write none if no accommodations are needed.

*Please note, while we deeply value accessibility, our current location has a small set of stairs to navigate.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms