Get Tx Safe Haven Refuge Sliding Fee Scale 2015-2026

This guide provides clear and supportive instructions for filling out the TX Safe Haven Refuge Sliding Fee Scale online. The sliding fee scale assists users in determining their fees based on income, ensuring they receive the mental health services they need.

Follow the steps to complete the sliding fee scale form online.

1. Use the ‘Get Form’ button to access the TX Safe Haven Refuge Sliding Fee Scale form and open it in your chosen document editor.
2. In the first section, indicate your annual income by selecting the appropriate range. The ranges are as follows: below $20,000, $20,000 - $35,000, $35,000 - $50,000, and so forth, up to over $80,000. Each range correlates with specific fees for sessions.
3. Review the fee schedule based on your indicated annual income. For example, if your income is below $20,000, the fees for an intern, licensed mental health practitioner, and licensed mental health professional are $20, $35, and $50 respectively.
4. Note that the sliding fee scale can be adjusted based on the number of people living in your home. If your household has 2-4 individuals, it typically applies, but adjustments can be noted below the fee schedule if necessary.
5. If there are extenuating circumstances affecting your ability to pay, document these clearly in the space provided beneath the fee schedule.
6. Acknowledge that fees are subject to periodic adjustments, and if your income changes, you should inform Safe Haven Refuge to adjust your fee accordingly.
7. Review the financial agreement section carefully. Read the terms regarding payment methods and the responsibility for the return check fee. In the designated area, sign and date the form.
8. Once you've completed all sections, review the entire document for accuracy. You can then save your changes, download the completed form, print it for your records, or share it as needed.

Start completing your TX Safe Haven Refuge Sliding Fee Scale form online today!