Reduced Fee Application FormTherapy & CounselingPhiladelphia, PA Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneService Requested *Individual TherapyCouples TherapyFamily TherapyGroup TherapyConsultationPreferred Therapist *Caitlin SiekerkaClaire SavageCourtney MillerGrant MoralesIsabel CookLena HayesMadequor Tetteh-OclooNitasha StraitRachel BarnetteSara RosenbergYearly annual income level of household (verification of income through tax returns): *Financial Burdens *# of Dependents *Please note: For psychotherapy services, we require regular attendance to qualify for a reduced fee. If attendance becomes less frequent, we will resume regular therapy rates. Therapy clients must also agree that if your financial circumstances change (i.e., insurance benefits change, you or your partner get a raise or a job that enables you to increase the fee), you will let us know so we can resume the regular fee. Reduced fees are meant to be temporary. We will review this every 3-6 months. I agree to information reported in this application is correct and can be verified upon request. I agree to attend regular appointments in therapy. I understand I will no longer qualify for the reduced fee rate if I attend less frequently. I also agree to notify my therapist if my financial circumstances improve. (Sign first and last name) *FirstLastSubmit
