Payment Option Form
At this time, MaxOut Coaching and Therapy Services does not bill insurance for our services. As such all services are offered on a cash-pay basis. We accept cash, debit/credit, CashApp and PayPal. We do not want anyone to be without the help they need. Please complete the form below so that we may assess your financial situation and possibly offer financial assistance/alternate payment options for services rendered. 
Sign in to Google to save your progress. Learn more
Email *
Name *
First and last name
Email *
Phone number *
The cost for MaxOut Coaching and Therapy sessions is $150/hour, are you able to pay this cost out of pocket? *
How much can you afford to pay weekly to help offset the cost of your therapy? *
Do you have any skills that you would be willing to barter for therapy/coaching service? *
Do you have a job? *
Who is your employer? (Enter N/A if you are not working) *
What is your job title? (Enter N/A if you do not work) *
How many people live in your household? *
What is your annual household income from all sources? *
Do you currently have insurance? *
If you answered yes, who is your insurance provider? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dent Enterprises. Report Abuse
Google Forms