Sliding Scale Financial Information Form Confidential – for administrative use only Name * First Name Last Name Email * Household Income * Please indicate your gross (pre-tax) monthly income from all sources (employment; government benefits; support from family/partner; other income) Employment Status * Full-time Part-time Self-employed Unemployed Student Other Current Financial Challenges (Check all that apply) * High medical or mental health expenses Student loan or significant debt Supporting dependents or family members Recent job loss or income reduction Other Acknowledgment I understand that sliding scale rates are subject to reassessment every 6 months, and that fees may be adjusted if my financial situation changes. Date MM DD YYYY Thank you!
