Sliding Scale Application Name * First Name Last Name Email * Please indicate your annual household income: * <$39,000 $40,000 - $59,000 $60,000 - $79,000 $80,000 - $99,000 >$100,000 Current goals of therapy: * Desired frequency of sessions: * Community impact: please describe how continuing to access therapy services will enable you to contribute in a positive way in your family, workplace and/or community: * Do you have extended health benefit coverage? * Yes No If yes, please outline your coverage amount: Final comments - Is there anything else you want us to know? Thank you!
