Sliding Scale Fee Application

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Child's First and Last Name
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Caregiver's First and Last Name
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Caregiver's Phone Number
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Caregiver's Email Address
*

My child is:
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A new patient

An existing patient but continuing to pay the full fee would present a hardship

Do you have out of network benefits through your insurance?
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Yes

I'm not sure

Have you already asked for a gap exception and been denied?
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Yes

Have you already reached out to the Office of the Healthcare Advocate to see if there are any other options that can be pursued so that the cost of treatment is offset by your insurance?
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Yes

What is your annual income? Please include all sources of income.
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Are you and your child available for sessions during the day (e.g., 9am to 3pm)?
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Yes

What fee are you able to afford per session?
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Please tell me more about the need for a sliding scale fee.
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This form was created inside of Early Childhood Services of CT.