If you have questions about this form or about the sliding fee program, please email us at firstname.lastname@example.org.
If you don't know the answer to a question, it's OK to leave it blank.
Information about you:
Information about your children (if any):
Information about your spouse or the other parent if not married:
(leave unknown information blank)
If you have questions about this form or about the Sliding Fee Program, please email us at email@example.com.
IMPORTANT - I understand that by submitting this form I am not guaranteed to be accepted into the Sliding Scale Fees Program and there are further steps to complete the application process and to hire any professionals.
We expect to follow up with you within approximately 3-5 days to move forward with your application.