Name Of Potential Client To Receive Services *

Your BEST Email *

Your Phone Number *

Main reason(s) for pursuing services with us *

Without needing to go into too much personal detail, what are some reasons you feel you should be considered for financial assistance? *

Do you have any health care benefits, health spending account, or other insurance that may help to cover the cost? *

Are you requiring services due to a workplace injury or motor vehicle accident? If so, about when did it occur? *

Is there a percentage you feel you would be able to afford, possibly with the help of others who care about your health? *

75% - 165/hr

50% - 110/hr

25% - 55/hr

In the event that we are not able to offer a sliding scale at this time, would you be interested in being placed on a waitlist for future consideration? *

Yes Please

No Thanks

Payment in kind, or bartering of services (e.g., exchange of services or products) is something that we are not able to offer.

Although not a requirement, we do believe in paying it forward. We hope that you can find ways to offer something of worth like your time, talents, or finances to repay generosity. Be creative and find ways to dig deep in order to help others.