Accepted Therapy

Sliding Scale Fee Application

Date:

Sliding scale rate is based on family size and annual income. This form will be help me to figure out which level of the sliding scale you qualify for. This application will be reevaluated every six months or in the event of financial change in the household. The sliding scale rate is not applicable to anyone with insurance coverage that is in network with Accepted Therapy Services.

Household Members

Please list all dependent members of your household and their date of birth. If you have a dependent who is over the age of 18, additional information may be requested.

#	Name	Relationship to you	Date of Birth
1

Household Expenses

This is a list of all of your monthly household expenses. I will take these expenses into consideration when determining your sliding scale fee rate.

Rent/Mortgage
Electricity
Water/Sewer/Gas
Car Payment(s)
Phone
Insurances (car, home, renter)

Household Income

Total all sources of income for each box and place the total amount in the second column. Then denote whether the income is received monthly or annually.

(Please be available to provide supporting documentation of your income upon request.)
Source of Income	Amount	Frequency
Wages, salaries, or tips		Montlhy Annually
Unemployment Worker’s comp. Social Security Disability Public assistance Survivor benefits Pension or retirement		Montlhy Annually
Child Support Rent Royalties Alimony		Montlhy Annually
		Montlhy Annually

I understand that I am being considered for a sliding scale fee at Accepted Therapy Services. I also understand that I may not meet criteria for a sliding scale. I further understand that that if my financial situation changes, I am expected to notify Accepted Therapy Services prior to my next session so that my sliding scale rate can be reassessed for need.

Signature box