Application for Fee Adjustment

Client Name:(Required)
First Last
Parent/Guardian (if client under 18):
First Last
WEEKLY Household Income (Total of all household members):(Required)
Family Members
Self:(Required)
First Last
Spouse/Partner:
First Last
Dependents and their ages:
Enter name and age for each dependent.
Proof of Income
(Only One Item Needed)
First 2 pages of current Income Tax Return OR Latest Pay Check Stub:
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 2.
Scan/Take Picture
If Unemployed:
Date of last unemployment benefits distributed:
Month
Day
Year
Date of unemployment:
Month
Day
Year
Describe Financial Hardship:(Required)
Consent and Signatures
I/we have read and understand the information regarding the fee adjustment policies of the Samaritan Center. I/we agree to inform my/our therapist of any change in the above financial information (both increases and decreases).
Client/Responsible Party:(Required)
First Last
Email Address(Required)
Date
MM slash DD slash YYYY
1. Fee adjustments are based on the amount of money you can contribute, any insurance payments available, and contributed support from the Samaritan Counseling Center of Southeast Texas.
2. In accepting a fee adjustment from the Samaritan Counseling Center, you agree to inform your therapist of any changes in your family income, whether increases or decreases.
3. Fee adjustments are granted for 6 sessions. As those sessions near completion, you and your therapist will need to discuss appropriate next steps. If you continue with therapy sessions after the 6 initial sessions the Fee Adjustment rate increases in $5.00 increments every 6 sessions. For example, if you pay $25.00 for the first 6 sessions, your next 6 sessions will increase to $30.00 per session and so forth.
4. Fee adjustments are not given on any missed appointments under 24 hours noticed, or no call no shows. The full fee will be billed and due at your next session along with your regular approved fee for sessions.
5. Samaritan Counseling Center makes contributions to client fees through various Samaritan funds. Money for these funds comes through charitable contributions from individuals, groups, service organizations, churches, businesses, and corporations.
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Application for Fee Adjustment

Family Members

Proof of Income

Consent and Signatures