Sliding Fee Scale Scholarship Application Sliding Fee Scale ApplicationApplication for a Sliding Fee Scale Scholarship for Counseling ServicesThis form is only to be filled out if you are uninsured or have Medicare insurance. This Scholarship is only applicable to individual counseling sessions and does not apply to any type of testing or assessment. Please read each statement and sign to indicate your agreement.I understand my per session fee will be between $20 and $120.00 per session.I understand that fees for counseling are based on GROSS annual income from all sources/members in your home.I understand and agree that payment is due when services are rendered unless an arrangement has been made in advance. If I have an unpaid balance when I terminate my counseling, I agree to make monthly payments until the balance is paid in full.I agree to pay a $35.00 fee if I do not show for or cancel an appointment without giving at least 24 hours notice. I understand that the counselors providing the sliding fee scale may be interns, or counselors working toward the counseling hours mandated by the state for full licensure.I understand that I am to report any major changes in income and/or family status as soon as the change takes place. Enter your total Yearly family income from all sources.How many individuals live in your home with you?Client NameTodays DateSubmit Form
