Sliding Scale Form

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Please Choose One *

New client & unable to pay full fee Current client & unable to pay fee increase Current client & unable to pay full fee

Service *

Individual Therapy Couple Therapy Group Therapy

What is the maximum fee you could pay per session?

Enter max. fee *

Do you have out-of-network benefits for mental health?

Choose One *

Yes No I don't know

If Yes, please describe your benefits. *

Are you available during weekday daytime hours (10am-4pm)?

Yes/No *

Annual Income (please include all sources of income, including family contributions). You may be asked to verify this income with a pay stub or financial statement

Income *

Reasons why you are unable to pay the full fee. Please provide any details that may help us understand your need for a lower fee, such as loss of income, medical expenses, significant debt, etc

Reasons *

Submit

Sliding Scale FAQ

Who is eligible for the sliding scale?
NYCCT offers a sliding scale fee for those who cannot afford the full fee. The sliding scale is designed to help those who do not have out of network coverage or have high insurance deductibles. The scale is based on availability and financial need.

How do I know if I'm eligible?
In order to be eligible for the sliding scale, you must apply and provide income information and an explanation of why you cannot pay the full fee. Although in most cases sliding scale is offered on an honor system, we may occasionally ask for you to verify your income (with a paystub or financial statement).

How long can I receive a sliding scale rate?
Sliding scale rates are approved for a duration of 6 months at a time. If at any point during that time your income situation changes, please communicate this to your therapist. After your rate expires, you will default back to the full fee unless you re-apply for sliding scale and are approved. Generally, there is a limit to how many times a sliding scale will be approved and you can expect to eventually default to the full fee. For this reason, we ask that you consider sliding scale a benefit that is intended to help you bridge a time of financial hardship, rather than a permanent change in your fee.

What time slots are eligible?
Time slots are based on therapists availability. We see clients weekday morning, afternoon, and evenings, and also have some availability on Saturdays and Sundays.

Sliding Scale Form

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