Sliding-Scale Payment Assistance Application
Download the full confidential application, complete it, and call (234) 237-4488 to arrange a confidential way to return it and any supporting documents.
Download the full application (PDF)Submitting an application does not guarantee approval. Approved fees will be communicated before services begin.
DEEPER FOCUS LLC
Sliding-Scale Payment Assistance Application
Confidential – Financial Assistance Request
Purpose
Deeper Focus LLC is committed to providing accessible, compassionate, and affordable behavioral health services. Our Sliding-Scale Payment Assistance Program offers reduced fees to eligible individuals based on household income, household size, financial circumstances, and demonstrated financial hardship.
Approval is based on available program resources and individualized financial review. Clients will receive a written decision identifying any approved reduced fees.
Section A: Client Information
Client Full Name: ___________________________________
Date of Birth: ______________________________________
Parent/Guardian (if applicable): ______________________
Phone Number: _____________________________________
Email Address: _____________________________________
Date of Application: _________________________________
Preferred Method of Contact: ☐ Phone ☐ Email ☐ Mail
Section B: Insurance Information
Current Insurance Status:
☐ I do not have health insurance.
☐ I have private health insurance but am requesting self-pay services.
☐ I recently lost my health insurance coverage.
☐ I have applied for Medicaid or other health insurance and am awaiting a decision.
☐ I have Medicare or Medicaid coverage.
☐ Other: _____________________________________________
Clients enrolled in Medicare, Medicaid, or another federally funded insurance program will receive a separate eligibility and billing review before any discounted payment arrangement is offered.
Section C: Household and Income Information
Number of People in Household: ______________________
Number of Dependents: ______________________________
Total Gross Household Monthly Income: $______________
Estimated Gross Annual Household Income: $____________
Primary Source(s) of Income (check all that apply):
☐ Full-time employment
☐ Part-time employment
☐ Self-employment
☐ Social Security / Disability
☐ Unemployment benefits
☐ Retirement / Pension
☐ Financial support from family or others
☐ No current income
☐ Other: _____________________________________________
Section D: Financial Hardship Assessment
Are you currently experiencing financial hardship?
☐ Yes ☐ No
Please select any circumstances affecting your ability to pay:
☐ Unemployment or reduced working hours
☐ Housing instability or homelessness
☐ High medical expenses
☐ Disability-related financial hardship
☐ Unexpected family emergency
☐ Loss of household income
☐ Significant caregiving expenses
☐ Recent separation, divorce, or death in family
☐ Other: _____________________________________________
Optional: Briefly explain any circumstances you would like Deeper Focus LLC to consider when reviewing your application:
Section E: Financial Documentation
To support this request, applicants may provide one or more of the following:
☐ Two recent pay stubs
☐ Most recent tax return or W-2
☐ Social Security / Disability income statement
☐ Unemployment benefit documentation
☐ Written statement of no income
☐ Other proof of income or financial hardship
☐ Documentation unavailable; alternative verification requested
Please do not submit bank account numbers, Social Security numbers, or unrelated medical records.
Section F: Requested Financial Assistance
Services Requested:
☐ Initial Diagnostic Assessment
☐ Individual Counseling
☐ Family Counseling
☐ Group Counseling
☐ Other: _____________________________________________
Amount I Believe I Can Afford Per Individual Therapy Session:
☐ $50 ☐ $65 ☐ $80 ☐ $95 ☐ Standard Rate
☐ Other amount requested: $________________
Anticipated Frequency:
☐ Weekly
☐ Biweekly
☐ Monthly
☐ Other: _____________________________________________
Section G: Client Acknowledgment and Agreement
By signing this application, I acknowledge that:
I certify that the financial information provided is accurate to the best of my knowledge.
I understand that submitting an application does not guarantee approval.
I understand that the approved fee and effective dates will be provided in writing.
I agree to notify Deeper Focus LLC of significant changes in my insurance coverage or financial circumstances.
I understand that I am responsible for any agreed-upon fees for services received, consistent with the practice's financial policies.
My financial information will be maintained confidentially and accessed only by authorized personnel for legitimate administrative purposes.
I understand that I may request reconsideration if my financial situation changes or if my application is denied.
I understand that financial assistance decisions will not determine my clinical diagnosis or treatment recommendations.
Client/Guardian Signature: __________________________
Date: ____________________________________________
Section H: Administrative Use Only
Application Received: _______________________________
Reviewed By: _____________________________________
Documentation Status:
☐ Complete
☐ Additional information requested
☐ Alternative verification accepted
Household Size: ___________________________________
Verified/Reported Annual Income: $___________________
Financial Hardship Considered: ☐ Yes ☐ No
Standard Session Rate: $____________________________
Approved Individual Therapy Rate: $__________________
Approved Other Service Rates (if applicable):
Decision:
☐ Approved
☐ Approved with individualized hardship exception
☐ Additional documentation needed
☐ Denied
Reason/Explanation:
Effective Date: ____________________________________
Expiration / Review Date: ____________________________
Approving Administrator: ____________________________
Signature: ________________________________________
Date: ____________________________________________