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Application for sliding fee scale for Katie Grant LCPC, LLC
To be completed when interested in a lower-than-usual price based on income. The chart to determine fee discounts can be found
here
.
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* Indicates required question
Email
*
Your email
First name (preferred name)
*
Your answer
Legal name (first and last)
*
Your answer
What is your date of birth?
*
MM
/
DD
/
YYYY
I am requesting sliding fee scale for:
*
Hourly therapy services
EMDR Therapy Intensive
What is the size of your household, including yourself? (Enter number of people)
*
Your answer
Will you be using a twice monthly paycheck, a monthly income (net), or a yearly income (net from taxes last year)?
*
paycheck amount I/we receive twice per month
paycheck amount I/we receive each month
net income from last year's taxes
Required
Please enter the amount below.
*
Your answer
By entering today's date below, you are promising that the above information is true and accurate. You will receive an email copy for your records. You will later receive an email stating what your level of discount is.
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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