Financial Assistance Application

Alibi Health is committed to making mental health care accessible. If you are experiencing financial hardship, you may be eligible for a sliding scale fee or a payment plan. Please complete the form below to help us determine your eligibility.

This form is securely linked to a HIPAA-compliant patient portal to protect your privacy and confidentiality.

First name*

Last name*

Phone Number

Email*

Date of birth*

Month

Day

Year

Do you currently have health insurance?*

Yes

Do you anticipate having a loss or change in health care coverage soon?

Yes

Household Size (including yourself):*

Annual Household Income*

Are you facing any financial hardships that impact your ability to pay for care? (Check all that apply)

Job loss

Medical expenses

Low income

Support dependents

Other

Briefly describe your current financial situation and why you are requesting financial assistance*

Are you interested in a payment plan, sliding scale fee, or both?*

Payment Plan

Sliding Scale

Both

What services are you inquiring about? (Check all that apply)*

Individual Therapy

Family Therapy

ADHD Coaching

Case Management

Other

Financial Assistance Disclaimer

A limited number of sliding scale and payment plan spots are available and are filled on a first-come, first-served basis. Submitting an application does not guarantee approval, as financial need is determined by Alibi Health based on income, household size, and individual circumstances. We encourage applicants to provide as much detail as possible to help us assess eligibility. If approved, we will discuss the available options that best suit your needs.

I declare that the info I’ve provided is accurate and complete.

Signature

Signature field is empty.

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