Reduced Fee Application - Pivotal Counseling Center

Person Completing this Form *

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Last

Phone Number *

Email *

Client Name *

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Last

Annual Household Income *

Household Size *

Household size consists of the individual and all persons whom such individuals expect to claim as a tax dependent.

Which Therapist are you planning to see?

Financial Need Statement

Please explain why you are requesting sliding scale fee, i.e., loss of job, disability, other financial hardships, etc.

Optional Additional Information

I understand that this is not a guarantee of a reduced fee. *

By clicking YES below, I attest that the information provided above is accurate and a truthful representation of my financial hardship. I understand that if I misrepresented my financial hardship that any agreement will become null and void and I may be subject to full fee charges. I understand that this reduced fee will be approved for a period of 6 MONTHS at which time I must re-apply to determine if I am eligible for continued eligibility. I agree to notify the Pivotal Counseling Center if there is a substantial change in my household’s financial situation. This may include a change in employment or insurance status. *