Making Health Coaching More Accessible

We believe everyone deserves access to quality health coaching services. To support individuals and families with varying financial circumstances, we offer a limited number of reduced-cost coaching packages through our Community Access Sliding Scale Program.

Eligibility

Discounted rates may be available based on household income and financial circumstances.

Applicants may be asked to provide documentation verifying household income, such as:

• Most recent federal tax return

• W-2 form

• Recent pay stubs

• Social Security benefit statements

• Other income verification documents

Privacy

Applicants may redact Social Security numbers, account numbers, and other sensitive information before submission.

All documentation is used solely to determine eligibility for reduced-cost services and is not shared with third parties except as required by law.

Application Process

1. Complete the Sliding Scale Application.

2. Submit any requested income verification documents.

3. Receive confirmation of your eligibility and coaching rate.

4. Begin your coaching program.

Availability

Sliding scale coaching packages are offered on a limited basis and are subject to availability.

Discount levels and eligibility requirements may be modified periodically at the discretion of the practice.

Questions?

If you believe financial circumstances may prevent you from accessing coaching services, we encourage you to apply. Our goal is to make health coaching more accessible while maintaining the sustainability of our programs.

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Community Access Sliding Scale Application

Applicant Information

Full Name:

Email Address:

Phone Number:

Preferred Method of Contact:

☐ Email

☐ Phone

☐ Text Message

Household Information

How many people live in your household, including yourself?

☐ 1

☐ 2

☐ 3

☐ 4

☐ 5

☐ 6+

Number of adults in household:

Number of children or dependents in household:

Household Income

Please estimate your total annual household income before taxes from all sources.

☐ Under $25,000

☐ $25,000–$34,999

☐ $35,000–$49,999

☐ $50,000–$64,999

☐ $65,000–$79,999

☐ $80,000–$94,999

☐ $95,000–$109,999

☐ $110,000–$124,999

☐ $125,000 or more

Sources of household income (check all that apply):

☐ Employment

☐ Self-Employment

☐ Social Security Retirement

☐ SSDI

☐ SSI

☐ Pension

☐ Veterans Benefits

☐ Child Support

☐ Alimony

☐ Investment Income

☐ Other

Income Verification

To help us fairly allocate discounted coaching services, please upload one of the following:

☐ Most recent federal tax return

☐ W-2 form

☐ Recent pay stub(s)

☐ Social Security benefits statement

☐ Disability benefits statement

☐ Other proof of income

File Upload:

[Choose File]

Accepted Formats: PDF, JPG, JPEG, PNG

Applicants must redact Social Security numbers, account numbers, and other sensitive information.

Financial Circumstances (Optional)

Please briefly describe any financial circumstances that may impact your ability to pay for health coaching services.

Examples may include:

• High medical expenses

• Disability-related expenses

• Caregiving responsibilities

• Job loss

• Reduced work hours

• Other financial hardships

Coaching Goals

What are your primary health and wellness goals?

☐ Weight Management

☐ Nutrition Improvement

☐ Physical Activity

☐ Stress Management

☐ Chronic Disease Prevention

☐ Healthy Aging

☐ Habit Change

☐ General Wellness

☐ Other

Please describe your goals:

Certification and Agreement

I certify that the information provided in this application is true and accurate to the best of my knowledge.

I understand that submission of this application does not guarantee approval for a discounted coaching rate.

I understand that discounted coaching packages are offered on a limited basis and subject to availability.

I understand that any documents submitted will be used solely for eligibility determination and will be handled in accordance with applicable privacy practices.

☐ I certify that the information provided is true and accurate.

Applicant Signature:

Date:

Office Use Only

Application Received Date:

Income Verification Received:

☐ Yes

☐ No

Approved:

☐ Yes

☐ No

Discount Level Assigned:

☐ Standard Rate

☐ 10% Discount

☐ 20% Discount

☐ 35% Discount

☐ 50% Discount

Reviewed By:

Date: