Request for Sliding Scale Fee
I offer three need-based sliding scale appointments in my private practice. If you qualify for sliding scale, you commit to attending weekly or bi-weekly sessions. The sliding scale rate is valid for 6 months. This form helps us discern between need and strong preference for a reduced fee. I understand that frank discussions about resources may be uncomfortable, and it is only through your honest, transparent disclosure that I may offer you a rate that works for you, and keeps me in business. Thanks for taking the time to think this through. All of your answers will be kept completely confidential. Please note that if you own a home, have an earning partner or can be reimbursed for your sessions, you do not qualify for sliding scale.
What is your name?
Why are you asking for sliding scale fee?
What was your annual gross income in 2018? (Line 22 of your 1040 form if in the US)
Any other sources of income? (Partner income, spousal support, dividends, child support, etc.) If so, how much annually?
How many dependents do you have?
How many vacations did you take in the past 12 months?
Do you own any assets, like a home, stocks, savings accounts, property etc? If so, please describe.
Through your employer, do you have an FSA, HSA or other means of being reimbursed for out-of-network expenses like our work together?
How much do you feel like you can contribute per session?
Can you tell me a bit about how you are financially prioritizing this work?
Do you have any special or extenuating circumstances I should know about in considering your request for reduced fee services?
Thanks for filling out this form. I know it's sensitive to talk about money. Often the way we embody money and sex are similar. Sharing this information is the start of our conversation about the appropriate fee for our work together.
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