Fee Reduction Request Form
Family Service of El Paso has a Fee Reduction policy that allows therapists to submit a request to support their clients. Reductions are based on family size and annual income so that payment is not a barrier to services. Please provide the information below and your eligibility for a reduction will be determined by the FSEP administration team.
Therapist Information
Therapist Name
*
First Name
Last Name
Client Information
Please provide the information of the person currently receiving services from Family Service of El Paso.
Please select the type of therapy the client is receiving:
Individual
Family
Couples/Marriage
Group
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Family Members List:
*
Phone Number on file:
*
Please enter a valid phone number.
Do you or your family currently have any type of health care coverage/insurance?
*
Yes
No
Insurance Name:
Member Id:
Have you requested a fee reduction in the past six months ?
Please Select
Yes
No
Please provide additional information that explains why you or your family should be eligible for a reduced fee:
*
Household Information
Name of Head of Household
*
First Name
Last Name
Relationship to Client
*
Parent
Legal Guardian
Spouse
Client is Head of Household
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does client have any dependents?
*
Yes
No
List all the dependents of which Head of House is responsible for:
For multiple dependents, use the " + " icon to add each one
Dependents
*
Household Income verification
Is Head of Household employed?
*
Yes
No
Place of Employment
*
Gross Monthly Income
*
Please Upload Proof of Income.
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This could be the latest paystub
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of
Additional Financial Information
Does client have other sources of income?
*
Yes
No
List Other Sources of Income.
*
Please Upload Proof of "Other" Income
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Drag and drop files here
Choose a file
this could be the latest statement including bank deposits from source
Cancel
of
Counseling Fee
Indicate the current fee and the fee you think you can afford based on the income you are reporting on this fee reduction request.
Click the "+" to add multiple services
*
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Clients Acknowledgment
BY SIGNING BELOW, I CERTIFY THAT FAMILY SIZE AND INCOME INFORMATION PROVIDED IS TRUE AND COMPLETE. I AGREE TO INFORM MY THERAPIST FROM FAMILY SERVICE OF EL PASO AND/OR THEIR OFFICE STAFF OF ANY CHANGES IN MY FINANCIAL STATUS WITHIN THE NEXT 4 MONTHS TO HAVE MY COUNSELING FEE REASSESSED AS PER THE FAMILY SERVICE OF EL PASO FEE REDUCTION POLICY.
** Please note that reduced fee is not effective until APPROVED. Reduced fees are not retroactive; hence, fees prior to approval date of this request remain the same.**
- Finance & Administration Office
Client Signature
*
Submit
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