Client Income Verification
Please submit income verification to support your request for sliding scale fee/payment plan options. If your income is fixed and does not fluctuate from pay period to pay period, please submit a copy of your most recent paystub. If your income fluctuates from pay period to pay period, please feel free to submit your most recent W2/1099.
My Name
*
First Name
Last Name
Clinician's Name
*
Today's Date
*
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Month
-
Day
Year
Date
First Income Document
*
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Second Income Document
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Submit
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