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.
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.
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.