Financial Hardship Form

On Demand Counseling allows patients to apply for a reduction in cost of services if the patient informs the clinic that they cannot make the full payment amount. If you feel that you cannot meet the payment amounts for services needed, you may apply for a reduction in cost by filling out this form. If you meet the criteria for a financial hardship, a determination of cost will be made.

Independent of cost determination, the initial fee for a cash paying client is $240 for the first visit, which is due at the time of the service.

Patient Name

Today's Date

Date of Birth

Phone

Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Are you currently:

UnemployedDisabledEmployed

If employed, what is your monthly income?

If employed, what are your monthly expenses?

I hereby acknowledge that the information given is true and correct. I authorize On Demand Counseling to verify any information contained in this document for the sole purpose of assessing financial need.

Signature