Katy Gladwin and Sacred Roots Financial Assistance Application
I am happy to offer discounted services as I am able. Special consideration is taken for LGBTQ and POC. Please fill out this entire form and I will be in touch as soon as I can. Thank you.
Personal Information
Full Name *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Zip *
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Email *
Your answer
Preferred phone number *
Your answer
Mother's birthdate *
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YYYY
Baby's due date *
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DD
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YYYY
Partner's full name *
Your answer
Preferred phone *
Your answer
Provider's name *
Your answer
Provider's phone *
Your answer
Where are you planning to have your birth? *
Your answer
Is this your first birth? *
If no, what were your previous births like?
Your answer
How did you hear about me?
Your answer
Which services are you applying for fee assistance? *
Required
Fee Assistance Information
Please know that EVERY question must be answered in order for us to consider you for fee assistance. We will NOT process incomplete applications.
How many people live in your home? *
Your answer
What is your total income before taxes? *
Your answer
Do you receive some sort of public assistance? If yes, please explain. *
Your answer
Do you have any specific needs or unique circumstances we should be aware of? *
Please let me know if you identify at LGBTQ or as a POC.
Your answer
By clicking "Submit" I hereby recognize that all the above information I provided is true and correct, and understand that this information will not be publicly shared.
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