Self pay

Our self-pay sliding scale is based on income and will be discussed with you prior to your first appointment. Please click the button below to fill out our self-pay form.

Sliding Fee Discount Information

Affinity Counseling Services' policy is to provide essential services regardless of the patient’s ability to pay. Affinity Counseling Services offers discounts based on family size and annual income. Please complete the following information and return it to the front desk to determine if you or your family members are eligible for a discount. The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.

Self Pay Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Household Information

List the full name and birth date of each person, including yourself

Income 1

List everyone who works in the household and their gross wages, salaries, tips, etc

Income 2

Income from business and self-employment

Income 3

Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, veterans’ payments, survivor benefits, pension or retirement income

Income 4

Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources

Total Income

Please add up all the previous income totals and put here

Signature

My adding your name to this blank you certify that all information on this application is factual to the best of your knowledge.

Today's Date

YYYY

Affinity Counseling Services Sliding Scale Policy

If you are already a self-pay client and need to set up a payment method click the button below.

Set Up Payment

Self Pay Client Resources

The self-pay option can often have a longer waiting time due to the availability of our therapists. The resources listed below offer

private insurance options to lower to mid-level income houses at discounted prices
financial assistance for those who cannot obtain insurance, have high deductibles, or otherwise fall between the gaps in healthcare.

We are committed to helping you receive the care you need.

Self pay

Self Pay Client Resources

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