sliding fee scale application

Nashville Emotional Wellness (NEW) Counseling PLLC offers a sliding fee scale to NEW clients who do not have insurance. It is our policy to make mental and emotional health services both accessible and affordable to all regardless of ability to pay. NEW Counseling PLLC offers discounts based on family size and annual income in accordance with federal poverty guidelines. Clients utilizing the sliding fee scale must complete this form and recertify every 6 months or if and when your financial situation changes. All applicants will be required to provide income documentation (most recent pay stubs, most recent federal tax forms, P& L Statement for business and self employment income) once contacted by administrative team. Additional information about the Federal Poverty Guidelines can be found here.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Household Members

Please add the name and date of birth for all household members.

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Additional Household Members

Please add any additional household members names and DOB in the space provided.

Total Number of Household Members

Income Sources

Check all that apply.

Gross wages, salaries, tips, etc.

Income from business and self-employment

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income

Other

If other, please provide detail

Total Amount of Income

Please add total for each household members income.

Expenses

Please list all household expenses.

Additional Information

Please use this are to provide any additional information you would like considered in your sliding fee scale application.

I certify, that the family size, income and expenses information shown above is all correct and true to the best of my ability.