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FINANCIAL DISCLOSURE FORM
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| The Episcopal Counseling Center is
not externally funded to cover the expenses of providing psychological
services. Therapists are not salaried but are paid a percentage of their
client payments. As a ministry, we offer an adjustment on the fee for those families and individuals whose GROSS yearly income is less than $70,000. This gross amount is based on total household income. To become eligible for the fee reduction, we must have a listing of all sources of income and benefits and their yearly amounts. In the event that you determine this information to be too private or personal, the sliding scale will be waived and the full fee of $125.00 per hour will be charged. If someone other than the client will be paying this bill, please ask for the Financial Agreement form. If there is a concern about the fee you are being charged, please discuss it with your therapist. |
| Place of Employment | Gross Yearly Income | |
| Man/ Husband: | $ | |
| Woman/ Wife | $ | |
| Alimony (paid to you) | $ | |
| Child Support (paid to you) | $ | |
| Dividends/ Interest | $ | |
| Government Assistance | $ | |
| Other Sources | $ |
I certify by my signature below that this information is an honest and accurate representation of the total sources of income and revenues. I further understand that the Counseling Center pledges not to reveal this information to anyone without my consent.
___________________________ _____________
______________________________________
(CLIENT or guardian signature)
(DATE)
(CLIENT PRINTED NAME)
1021-A East Robinson Street * Orlando, Florida 32801 * (407) 423-3327 * (800) 544-1817