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

First Name *

Last Name *

Gender *

Counselors name *

Address Line 1

Address Line 2

City

State

Zip

Cell Phone *

Work Phone

Email *

FAMILY INFORMATION

Your children

Child #1 Gender

Child #1 Age

Lives in the same house?

Child #2 Gender

Child #2 Age

Lives in the same house?

Child #3 Gender

Child #3 Age

Lives in the same house?

Child #4 Gender

Child #4 Age

Lives in the same house?

Child #5 Gender

Child #5 Age

Lives in the same house?

Employment / Income Information

Your Employer

Your Current Profession

Monthly income before deductions

Is your spouse employed?

Spouse's employer

Spouse's current profession

Spouse's monthly income before deductions

REASON FOR SEEKING COUNSELING

What specific issue(s) in your life are your hoping will be addressed through the counseling process?

REASONS FOR REQUESTING A REDUCED RATE OR SLIDING SCALE

What specific needs do you have that you feel are important to determining if you qualify for receiving a reduced rate or sliding scale for pastoral counseling services?

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.

Date *

Initial to sign *

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