UIRC Sliding Fee Scale Application
We know that family building is expensive. We want individuals managing infertility to have access to affordable mental health counseling. Please apply if you feel you would benefit from reduced cost sessions. Reduced and sliding fee scale sessions are limited to 8 per client in order to accommodate the many who are also struggling with the mental and emotional impact of infertility. Extensions are approved on a case-by-case basis by the UIRC Clinical Committee.
Name *
Your answer
Date of Birth *
Your answer
Total yearly household income from all sources. *
Number of people in household. *
Your answer
Please describe any extenuating circumstances. (Temporary job less, illness) *
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service