Sliding Fee Form

Private/Sliding Fee $ Per Hour:

Or $ Group Session:

To be determined prior to 1st appointment, re-evaluated annually)

Client Name *:

Client Date Of Birth *:

Address *:

Apt/Suite #:

City:

State/Province:

Zip/Postal Code:

Country:

Phone *:

Gender *:

Marital Status *:

Employment *:

Household Income *:

Household Size *:


Billing Information
First Name *:

Relation *:

Phone *:

Address *:

City:

State / Province:

ZIP / Postal Code:


Signature Of Financially Responsible Person *:

Date *: