Sliding Scale Worksheet Page 2
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2Monthly Household Expenses
We do not include basic costs that everyone pays such as rent, food, transportation, etc, but extra costs unique to different
circumstances and communities.
Y / N
Number of dependents _____ x $335 monthly deduction
$
(based on 2015 Federal Dependent Exemptions)
Transitioning Expenses (for Trans-Identified Clients)
Y / N
$
Y / N
HIV and AIDS medications and related services
$
Y / N
Child Care
$
Y / N
$
Tuition/Educational Expenses/Student Loan Payment
(not including living expenses)
Y / N
Immigration-related Expenses
$
Y / N
Funds given to other adult earner/s in household
$
Y / N
$
Remittances sent to home country
Other medical expenses
Y / N
$
n ot covered by insurance or extenuating circumstances.
Please describe:
S um of Monthly Expenses = ‘D’ $ _ ___________
Your Total Net Monthly Household Income = ‘E’
Subtract: Income ‘C’ _ ______ – Expenses ‘D’ _ ______
$ _ ___________
‘ E’
=
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Reference our Sliding Scale Fee Chart to input your Sliding Scale Rate per Service below:
Private Acupuncture (60 min) $________
Private Acupuncture / Tui Na Combo (75 min) $________
Community Acupuncture
$________
Massage Therapy (60 min)
$________
Herbal Consultation
$________
Massage Therapy (90 min)
$________
Private Yoga Session
$________
_______
Thank you for participating in the sliding scale process with us!
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Parent category: Medical