Application for Sliding Scale Membership

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We have a limited number of FREE sliding scale memberships available. Please submit your application below, and we will contact you within 2 weeks to let you know the status of your approval.

This sliding scale program is meant to increase access to therapeutic services for those who do not have the privileges of socioeconomic stability and reliable health care. This practice recognizes that privilege is systemic in our society and not based solely on income. If you have financial peace of mind, please pay full price for your session. If you do not experience such privilege, please complete the application below to be considered for one of our limited memberships.

As of 3/2023, we have 9/20 memberships available.

Email *

Your full name *

DOB *

YYYY

Cell phone number *

Please describe your goals for treatment:

Why do you want to receive services at Metta? For example, are you recovering from a particular musculo-skeletal injury? Working to manage a mental health diagnosis or condition? Seeking general wellness?

Short-term or Ongoing care? *

In order to keep this option available for new applicants, we will be cancelling memberships that go unused. Please indicate whether you are seeking short-term (e.g. one-time) or ongoing (e.g. monthly) care. Year-long memberships that are unused for 4 months will be cancelled. Short-term memberships are not counted in the quota and will be considered month-to-month.

One visit/short term (will be set up as 1-month membership)

Ongoing (will be set up as a year-long membership)

Other:

Does your household earn more than $70,000 in a year? *

1 point

Yes

Other:

Do you (personally) earn more than $30,000 in a year? *

1 point

Yes

Other:

Do you own your home, or live rent-free? *

(Also consider answering "yes" if you pay rent to a family member.)

1 point

Yes

Other:

Are your housing expenses (mortgage/rent) less than 1/3 your gross income? *

1 point

Yes

Other:

Do you have more than $2,000 in savings (excluding IRAs)? *

1 point

Yes

Other:

Have you received, or will you receive inheritance from your parents (not debt)? *

1 point

Yes

Other:

Are you confident that you (and your dependents) will have all the meals you need this week? *

1 point

Yes

Other:

Are you fluent in English? *

1 point

Yes

Other:

Did one or both of your parents graduate from college? *

1 point

Yes

Other:

Are you free of student loan, medical, and other large debts (excluding credit card debts that have been carried over for less than one year)? *

1 point

Yes

Other:

Are there any other financial hardship factors not represented above that you wish to elaborate for consideration?

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