Self Declaration
If you were not able to upload an ID, proof of income, or proof of address in your intake form, please complete the Self Declaration form below.
By submitting this form, you swear that you have no other income not reported below and understand that if your household income, family size or financial situation changes in any way, you will notify your therapist immediately for a possible change of my fee, based on the sliding scale maintained by YWCA Greater Austin.
By submitting this form, you understand that you am responsible for paying for your session each week. If you miss a payment, or have a balance, you understand that you must pay your entire balance in full at or before the next appointment time. If you do not do so, you understand that you will not be able to meet with your therapist. After your balance is paid you may request to be placed on the waiting list for another counseling appointment.
By submitting this form, you swear that the information below is true and accurate to the best of your knowledge and that you shall abide by these policies.