Reduced Rate, Sliding Scale and Benevolence Fund Application

Reduced Rate, Sliding Scale and Benevolence Fund Application

Instructions: Please complete the survey as accurately as possible, including any information that you feel could benefit the counseling process. All information contained in this survey is confidential except as prohibited by state / federal law regarding major criminal offenses and child, elderly, or disabled persons abuse.

 = required field

PERSONAL INFORMATION

PERSONAL INFORMATION

FAMILY INFORMATION

FAMILY INFORMATION

Marital Status

Your children

Employment / Income Information

Employment / Income Information

REASON FOR SEEKING COUNSELING

REASON FOR SEEKING COUNSELING

REASONS FOR REQUESTING A REDUCED RATE OR SLIDING SCALE

REASONS FOR REQUESTING A REDUCED RATE OR SLIDING SCALE

Note: Head to Heart Restoration Ministry does not turn anyone away based on finances but counselor availability and the number of sessions provided may be limited.