Sliding Scale Registration Form

Naseeha Mental Health offers sliding scales for those that may not be able to pay an entire therapy fee. A sliding scale is a flexible pricing system designed to make services more accessible based on an individual's financial situation. Please complete the registration form below to determine whether you are eligible for financial assistance. Our team will reach out to you via email to highlight next steps.

Full Name

Email Address

Phone Number

Age

Gender

City and Province of Residence

Reason for seeking therapy? Please include as much detail as possible.

Please attach your 2 most recent paystubs for one month. This will be used to calculate the reduced cost for therapy.*

Please attach your most recent paystubs for one month. This will be used to calculate the reduced cost for therapy.