Fee Reduction Request Form

Therapist Name*

First NameLast Name

Please select the type of therapy the client is receiving:

IndividualFamilyCouples/MarriageGroup

Name*

First NameLast Name

Date of Birth*

Date

Family Members List:*

Phone Number on file:*

Please enter a valid phone number.

Do you or your family currently have any type of health care coverage/insurance?*

YesNo

Insurance Name:

Member Id:

Provide duration of time needed

Acknowledgments for Fee Reduction Requests
I have read and fully understand the contents of this agreement. By signing below, I voluntarily agree to abide by all policies, procedures, and obligations described within. I understand that my signature constitutes a binding commitment between myself and Family Service of El Paso.

Please read and initial each statement below to acknowledge your understanding:

First Name    Last Name   ____ I understand that it is my responsibility to provide all requested documents on time for the processing or renewal of my fee reduction application.

First Name   Last Name   ____ I understand that all requested documents must be submitted within 72 hours of starting the application. If documents are not received within that timeframe, my application will not be processed, and I will need to reapply.

First Name   Last Name   ____ I understand that any approved fee reduction will take effect on the date my application was initiated. If the initiation date is after my previous fee reduction expired, I will be charged the regular session fee until approval is finalized.

First Name   Last Name   ____ I understand that the fee reduction I request is not guaranteed and is subject to review and approval by Family Service of El Paso.

First Name   Last Name   ____ I understand that if my application is delayed or incomplete due to my failure to provide the required information or documents, I will remain responsible for paying the regular session fee until a new fee reduction is approved.

First Name   Last Name   ____ I understand that if I wish to renew my application, it is my responsibility to be mindful of the expiration date, which occurs monthly on the date my application was originally submitted. I acknowledge that the front office will provide the expiration date at the time of approval.

Have you requested a fee reduction in the past six months ?

Please provide additional information that explains why you or your family should be eligible for a reduced fee:*

Name of Head of Household*

First NameLast Name

Relationship to Client*

ParentLegal GuardianSpouseClient is Head of Household

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does client have any dependents?*

YesNo

Dependents*

Is Head of Household employed?*

YesNo

Place of Employment*

Gross Monthly Income*

Please Upload Proof of Income.

This could be the latest paystub

Does client have other sources of income?*

YesNo

List Other Sources of Income.*

Please Upload Proof of "Other" Income

this could be the latest statement including bank deposits from source

Click the "+" to add multiple services*

Fee Reduction Request Form

Therapist Information

Client Information

Fee Reduction Information:

Household Information

List all the dependents of which Head of House is responsible for:

Household Income verification

Additional Financial Information

Counseling Fee

Clients Acknowledgment

Please note that reduced fee is not effective until APPROVED. Reduced fees are not retroactive; hence, fees prior to approval date of this request remain the same.

Fee Reduction Request Form

Therapist Information

Client Information

Fee Reduction Information:

Household Information

List all the dependents of which Head of House is responsible for:

Household Income verification

Additional Financial Information

Counseling Fee

Clients Acknowledgment

** Please note that reduced fee is not effective until APPROVED. Reduced fees are not retroactive; hence, fees prior to approval date of this request remain the same.**

Please note that reduced fee is not effective until APPROVED. Reduced fees are not retroactive; hence, fees prior to approval date of this request remain the same.