Sliding Scale Request Form
Please follow the steps listed below to submit your request for our sliding scale fee adjustment. The information provided here will allow you to determine the appropriate sliding scale tier for you based on your household AGI (adjusted gross income). This information must match the income verification documents that you have provided along with the criteria defined by the HCC sliding scale forms shared during intake.
Only completed forms will be considered for sliding scale fee adjustment. Session fees will remain at the full rate until the completed sliding scale form is received and approved by HCC. Sliding scale adjustments are provided on a case-by-case basis according to the discretion of HCC administrators and are subject to change over time.
Please note that your information will remain confidential, will be stored securely, and will be deleted after your request has been fully processed. HCC uses a private internal process to review and assess sliding scale needs. Please also note that funds are not unlimited so there are some limits to sessions for certain levels.
Thanks,
The HCC Team
NOTE: The sliding fee scale is based on the adjusted gross income (AGI) of a client’s single or joint tax return for the most recent year. Income must be determined on the basis of combined household income if the client is either married or considered a dependent of another household. If a client’s financial standing has changed significantly since the most recent tax return, the client should estimate AGI for the current year. Sufficient verification of income (e.g. tax return, current pay stub, earnings statement, etc.) must be provided by the client in order for reduced rates to be applied.
Session fees will remain at the full rate until income verification is received and approved by Harbor Christian Counseling staff.
Sliding scale options will be offered by request and will be given on an individual basis according to the discretion of Harbor Christian Counseling. Sliding scale fees are subject to change.
Harbor Christian Counseling does not accept insurance for payment of fees. Some insurance plans may offer partial reimbursement for out-of-network counseling services provided by licensed clinicians. All clients are encouraged to determine whether this is an option before proceeding with a sliding scale request. If the client will be requesting reimbursement from an insurance provider, the sliding scale cannot be applied. It is the client’s responsibility to correspond with their insurance provider and determine the availability and requirements for out-of-network reimbursement and to communicate this to Harbor Christian Counseling staff. Upon request, Harbor Christian Counseling will provide the client with additional documentation that is typically needed to file an insurance reimbursement claim.