Sliding Scale Application
Sliding fee scale rates are offered to Texas Music Therapy Services clients who have an annual household income below $120,000. We have a limited number of sliding scale slots, and we fill them on a first come, first served basis with priority given to clients with lower incomes. We ensure that all qualified applicants receive at least a small discount, and we strive to offer the largest available discount in the event that all slots at a given income level are filled.
Sign in to Google to save your progress. Learn more
Email *
Client's Full Name *
Your name, if different from client name
Email *
Phone Number *
Number of People in Household *
Total Household Income *
Acknowledgement
Acknowledgement
By clicking submit below, I affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and would subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform Texas Music Therapy Services, LLC if there is a significant change in my income.

 If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of Texas Music Therapy Services, LLC. I also understand that I will be required to provide proof of income before receiving any approved sliding scale discount. Proof of income may include one or more of the following items: Copy of yearly income tax return, copy of W-2  and/or 1099 form(s), previous 8 weeks of pay stubs or bank statements, copies of social security checks, or other checks you may receive as proof of household income.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Texas Music Therapy Services, LLC. Report Abuse
Google Forms