If you do not have insurance or EAP benefits, and the standard fee will cause significant financial hardship, you may apply for a reduced fee based on household size and income. This reduced fee must be agreed upon in writing and authorized by the Executive Director prior to your initial session.

Application for Fee Assistance (Samaritan Fund)

Frequency

Client Attestation

I understand that I am responsible for paying any balance I accrue. I understand this reduced fee is a scholarship based on current financial information given to the center at the time of intake. If at any time my financial situation changes, I will inform the Center and supply updated information to be used in the determination of a new fee arrangement. I further understand that if I have accrued a credit balance at the time of service termination, those additional monies on my account will be applied to reimburse the Center for any scholarship funds that I have received.

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