Financial Aid Application
Welcome! I'm so happy that you are ready to continue your journey to overcome codependency and chronic illness.

I I recognize that your individual circumstances are unique, which is I invite you to be open about your financial situation as we contemplate working together.

For those who are living on a limited budget or receiving a fixed income (such as Social Security Disability Insurance), I offer sliding scale fees and payment plans.

Please fill out the form below to apply and I will contact you within 24 hours with more details. All information you submit is confidential and stored securely, according to my privacy policy.

Sincerely,
Katherine Housh, RN, HWN-BC

Email address *
Name *
Your answer
Are you currently employed? *
Are you a full-time volunteer? *
Do you receive Social Security Disability Insurance? *
What is your total monthly household income *
How many dependents do you have? *
Your answer
Do you receive any additional sources of income, such as alimony, child support, or contributions from your parents? *
How much are you willing to budget for health coaching every month, even if it means making sacrifices in other areas of spending temporarily? *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service