Sliding Scale Fee Application

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At Perspectives Counseling Services, we believe everyone deserves a safe, compassionate space to show up as they are. Our sliding scale is here to make therapy more accessible—so you can focus on being seen, supported, and gently guided toward your own resilience.

This is a self-reported process. We trust your honesty and will use this information only to set a session fee that feels fair and manageable.

Sliding scale sessions are limited to 12 and fees will be renegotiated every three months or after the 12th session, whichever comes first. Clients must attend a minimum of 2 sessions per month to maintain eligibility unless other arrangements have been discussed. Frequent or late cancellations may terminate the agreement, with the possibility of reinstatement if circumstances allow.

We’re here to support you on your journey—because healing begins with connection, and no one should carry their pain alone.

Full Name: *

Date of birth: *

YYYY

Phone number: *

Email address: *

Who’s in your household?
*

Self

2-3 people

4 or more people

How’s your budget feeling these days?
*

I can cover full session fees without worry

I can manage most of the fee but could use a little help

I can only cover a small portion of the fee

Money is tight right now

Are there any financial stressors affecting your ability to pay for therapy? (e.g., medical bills, student loans, childcare, etc.)
*

What feels like a comfortable session fee for you? (per session)
*

How often do you hope to come to sessions?
*

Weekly

Every other week

Monthly

As Needed

Food check-in:
*

I have enough to eat, consistently

Sometimes I need a little extra help or assistance (e.g., SNAP, WIC)

I often don’t have enough to eat

Which best describes your housing situation?
*

Cozy and stable

Mostly stable, with some ups and downs

I’m juggling housing challenges

Utilities (electricity, water, internet, etc.):
*

All taken care of

Sometimes tricky to manage

Hard to keep up

Getting around:
*

I have reliable transportation

Sometimes it’s tricky to get where I need to go

Transportation is a struggle

Healthcare / Medications:
*

I can access what I need without problem

Sometimes it’s tricky

I struggle to access care or meds

Anything else we should know about your needs or life that might affect what you can pay?

By checking this box, I acknowledge that I’ve answered honestly so we can set a fee that feels fair.
*

Yes, everything is honest and accurate

Required

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