AMK Counseling

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AMK Sliding Fee Scale

NOTE: To comply with federal regulations, in order to give you a discount on our therapeutic services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence. You must verify your income at least every year. Please bring yearly income tax return, copy of your W‐2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive as proof of family income. Only the family size and annual income will be used to determine your eligibility and calculate your discount.

    Patient Information

    Today’s Date:

    First Name:

    Middle:

    Last:

    Other names:

    Home Address:

    City:

    State:

    Zip:

    Home Phone #:

    Home Phone #:

    Email:

    If you already linked with an AMK therapist what is their name?:

    Date of Birth:

    Type of Insurance:

    Do you have insurance?:

    Marital Status:

     

     

    Household Size:

    Name

    Date of Birth

    Relationship

    Name

    Date of Birth

    Relationship

    Household Income:

    Name

    Amount

    Frequency (Circle one)

    Employer:

    Name

    You

    Amount

    $

    Frequency (Circle one)

    Employer:

    Name

    Spouse

    Amount

    $

    Frequency (Circle one)

    Employer:

    Name

    Children

    Amount

    $

    Frequency (Circle one)

    Employer:

    Name

    Other

    Amount

    $

    Frequency (Circle one)

    Employer:

    TOTAL

    $

     

     

    Other Income

    You

    Spouse

    Children

    Other

    Subtotal

    Other Income

    Social Security

    You

    Spouse

    Children

    Other

    Subtotal

    Other Income

    Public Assistance

    You

    Spouse

    Children

    Other

    Subtotal

    Other Income

    Child Support, Alimony

    You

    Spouse

    Children

    Other

    Subtotal

    Other Income

    Other

    You

    Spouse

    Children

    Other

    Subtotal

    TOTAL

    $

     

    Please share any notable expenses which impact your need for aid:

    Please provide any additional information you would like to share:

    I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform AMK Counseling if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of AMK Counseling. I hereby acknowledge that I read the foregoing disclosure and understand it.

    Date:

    Name (Print):

    Signature: