Sliding Fee Discount Application

If you prefer to print this form and bring it in person, please click here.

Please note that if you print the form, you must come in person to our Riverside office, Monday through Saturday, between 9 AM and 5 PM to turn it in to a receptionist.

Name

First Name

Last Name

Preferred Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County

Phone

(###)

###

####

Secondary Phone

(###)

###

####

Date of Birth

YYYY

Name of Parent or Legal Guardian (if applicable)

First Name

Last Name

Current Therapist (if applicable)

Referral Service (if applicable)

Insurance (if any)

Employer (if any)

Primary Language

Primary Source of Income

Other Sources of Income (not including child support)

Number of People in Household