Sliding scale agreement 2026

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4.2 out of 5

53 votes

The document outlines a sliding fee scale for mental health services based on annual income, detailing fees for interns and licensed professionals. It includes provisions for adjusting fees based on family size and extenuating circumstances, emphasizes the importance of notifying the service provider about income changes, and specifies payment terms and conditions.

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Click ‘Get Form’ to open the sliding scale agreement in the editor.
Begin by reviewing the annual income brackets listed. Identify your income range and note the corresponding fees for both interns and licensed mental health professionals.
If applicable, document any extenuating circumstances regarding your ability to pay in the designated area below the fee schedule.
Read through the financial agreement section carefully. Ensure you understand that payment is due at the beginning of each session and note any fees associated with returned checks.
Sign and date the form in the provided fields to confirm your agreement with the fee schedule.

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2015	4.2 Satisfied (53 Votes)

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