JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Sliding Scale Fee Application
Money should not be a barrier to health! Provide the information below to submit an application for sliding scale based fees.
Sign in to Google
to save your progress.
Learn more
Full Name
Your answer
Physical Address
Your answer
Email Address
Your answer
Phone Number you can be reached at during the day
Your answer
What is your household annual gross income?
Your answer
How many people are in your household?
Your answer
Do you have any other sources of income or assets (house, cars, retirement account, investments, cash)?
Your answer
Describe your financial situation and any hardships you face.
Your answer
How will having access to Element Catalyst services improve your health and lifestyle?
Your answer
What are your short term goals?
Your answer
What are your long term goals?
Your answer
Anything else you would like to share?
Your answer
Please type your name below which acts as your legal signature indicating that all information you have provided in this application is true and accurate
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
