Sliding Scale Request

Required Field

Legal Name (if different from your chosen name)

I need to know your legal name for legal, insurance, and billing purposes. I understand that many people do not go by their legal names. If this is you, especially if your legal name is a dead name and you don't want to see it throughout my web portal, please provide your legal name HERE, and put your chosen name in the profile section below.

If your legal name is a dead name and is different from your chosen name, please write your legal name below

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Occupation

Contact Info

Home Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Sliding Scale

Bodywork Sliding Scale

30 minutes: $33-$50
1 Hour: $55-$100
1.5 Hours: $77-$150
2 Hours: $111-$222

Community Conflict Mediation Sliding Scale

$33-$100/Hour

If you need to pay on a sliding scale to be able to access my work, please answer the following questions below to the best of your ability.

Thank you for your honest reflections.

Are you applying to receive a sliding scale rate for bodywork or community conflict mediation?

community conflict mediation

bodywork / massage therapy

What rate are you hoping to pay for your service?

Characters: 0/255

What's your approximate monthly income AFTER taxes?

Do you have any dependents?

Yes

If you have dependents, how many do you have? Additionally, feel free to provide more context below.

How much debt do you have and what are your monthly payments like?

Characters: 0/255

Are you currently experiencing housing or food insecurity?

Yes

Do you frequently worry about having enough money to cover all your necessary bills?

Yes

Do you often struggle to make consistent payments on your debt?

Yes

Do you rarely if ever get to eat out or go on vacations due to financial constraints?

Yes

Do you lack generational wealth or family your can turn to for financial support?

Yes

Would you like to elaborate on any of your answers to the questions above or to share any more context about your situation?

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