Sliding Scale Fee Schedule for Individuals
It is my personal philosophy that a person’s financial circumstances should not determine their ability to receive grief support. The chart below offers a suggested sliding scale fee schedule based on yearly income. I do not require proof of income, I simply ask that you make an honest assessment of your situation. I trust and honor your decision.
Yearly Income Fee per session
$0 to $30,000 $35
$30,000 to $40,000 $40
$40,000 to $50,000 $50
$50,000 to $60,000 $60
$60,000 to $70,000 $70
$70,000 to $80,000 $80
$80,000 to $90,000 $90
$90,000 to $100,000 $100
$100,00 and above $110
Whatever fee you choose is due at the time of service. If you fail to keep an appointment without giving 24 hours prior notice (by calling 607-727-5332), you will be held responsible for the agreed upon fee amount.
The rate I choose is _____________________.
I understand that I am responsible to pay the above amount at time of service.. I further understand that without 24 hour notice of cancellation I will be charged the agreed upon fee for service, and that a service charge of $25 will be incurred for checks returned due to lack of finds.
Client signature___________________________________________________ Date_________________
Grief Support Provider signature___________________________________ Date__________________
It is my personal philosophy that a person’s financial circumstances should not determine their ability to receive grief support. The chart below offers a suggested sliding scale fee schedule based on yearly income. I do not require proof of income, I simply ask that you make an honest assessment of your situation. I trust and honor your decision.
Yearly Income Fee per session
$0 to $30,000 $35
$30,000 to $40,000 $40
$40,000 to $50,000 $50
$50,000 to $60,000 $60
$60,000 to $70,000 $70
$70,000 to $80,000 $80
$80,000 to $90,000 $90
$90,000 to $100,000 $100
$100,00 and above $110
Whatever fee you choose is due at the time of service. If you fail to keep an appointment without giving 24 hours prior notice (by calling 607-727-5332), you will be held responsible for the agreed upon fee amount.
The rate I choose is _____________________.
I understand that I am responsible to pay the above amount at time of service.. I further understand that without 24 hour notice of cancellation I will be charged the agreed upon fee for service, and that a service charge of $25 will be incurred for checks returned due to lack of finds.
Client signature___________________________________________________ Date_________________
Grief Support Provider signature___________________________________ Date__________________
