It is the policy of BEST PRACTICE PSYCHOTHERAPY to provide essential services regardless of the patient’s ability to pay. BEST PRACTICE PSYCHOTHERAPY offers discounts based on family size and annual income.
Please complete the following information and return it to the front desk to determine if you or members of your family are eligible for a discount.
The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.
Gross wages, salaries, tips, etc.
Income from business and self-employment
Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension, or retirement income
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources
I certify that the family size and income information shown above is correct.
