Access and affordability

Request sliding-scale consideration.

Share basic household and income information so we can review whether a reduced self-pay rate may be available.

Before you apply

A brief, private first step

Sliding-scale availability is limited and based on household income, household size, service needs, and current practice capacity. Submitting an application does not guarantee a reduced rate or an appointment.

Please protect your information

Do not provide a Social Security number, diagnosis, treatment history, insurance identification, financial documents, or other sensitive medical information through this form.

This form prepares an email in your device’s email application. You will review and send the email to info@theallianceperspective.com.

Contact and demographic information

Full name

Phone (optional)

Preferred contact

City and ZIP code

Age range

Household and service information

Number of people in household

Gross monthly household income

Primary income source (optional)

Service requested

Amount you believe you can afford (optional)

I certify that the information provided is accurate to the best of my knowledge. I understand that submission does not guarantee eligibility, a particular rate, or an appointment.