Financial Assessment

Zoom Counseling

Confidential Sliding Scale Financial Assessment

This form is used only to determine eligibility for a reduced counseling fee. Information provided will be kept confidential and used solely for determining your sliding-scale rate.

Client Information

Name:

Phone:

Email:

Date:

Household Information

Adults in household:

Dependent children:

Monthly Household Income

Include income from all adults contributing to the household.

Employment / Wages:

Social Security / Disability / Retirement:

Child Support / Alimony:

Other Regular Income:

Approx. Total Monthly Household Income:

Essential Monthly Expenses

Rent / Mortgage:

Utilities:

Food / Groceries:

Vehicle / Transportation:

Insurance:

Childcare:

Medical / Prescriptions:

Court-Ordered Payments:

Other Necessary Expenses:

Approx. Total Essential Expenses:

Financial Circumstances

Check any circumstances that significantly affect your ability to pay for counseling:

Job loss or significant reduction in income

Unexpected medical expenses

Single-income household

Caring for a dependent family member

Recent separation or divorce

Housing instability

Other significant financial hardship

Please briefly explain if needed:

Sliding Scale Determination - Office Use Only

$75 - Standard Fee

$60 - Reduced Fee

$45 - Supported Fee

$30 - Financial Hardship Fee

Effective Date:

Approved By:

Review Date:

Client Certification

I certify that the financial information I have provided is accurate to the best of my knowledge.

I understand that my sliding-scale fee is based on this information and may be reviewed if my circumstances change.

Client Signature:

Date:

Counseling Fee Levels: $75 Standard | $60 Reduced | $45 Supported | $30 Financial Hardship

Please notify the counselor if your financial circumstances materially change.