By signing the following document electronically, it is to be the legally binding equivalent of your individual handwritten signature.
In order to receive the sliding scale discount for office visits, you must document all household income. Documentation may be paycheck stub, income tax form, tax return, bank statements, or a letter from an employer. Forms of income include earnings from jobs, unemployment, disability, welfare, social security, interest income, gifts and income from property. Please report any changes to income at your next visit. The following must be completed prior to your first session in order to receive a discount.
Please list family members living in the same household, including children under the age of 18.
I hereby certify under Penalty of Perjury, that all of the information provided on this application is true and accurate, to the best of my knowledge. I understand that supplying false information on this form is a fraudulent act, under the laws of the State of California, which could result in civil or criminal penalties including fines and/or imprisonment.