Radical Healing Collaborative Appointment Request Form - Sliding Scale Therapy

Please read before completing form:

  • We will review your form and email you within 2 business days.

  • Weekly appointments will begin in September and end in April 2024.

  • These appointments will be offered on a sliding scale based on your self-assessment of your financial privilege. We will not ask you to share information on your income or assets with us.

  • Clinical Counseling Training Fellows are Master of Social Work and Clinical Mental Health Counseling candidates under the supervision of a licensed professional (the clinical supervisor).

  • Clinical Counseling Training Fellows provide individual therapy to adults and teenagers/children with adult consent. They do not offer couples or family therapy.

  • Your Clinical Counseling Training Fellow may request your permission to video record the appointment or for their clinical supervisor to attend. These measures are intended to ensure that you are receiving quality, ethical care. Recordings are stored on a HIPAA-protected server and solely used for the purposes of supervision. Video files will be destroyed once they have been reviewed. If a clinical supervisor attends your therapy appointment, they will not participate in the appointments. 

  • We will do our best to offer you care that is within your budget.

  • We will do our best to match you with a Clinical Counseling Training Fellow who aligns with your preferences. Please know that this is not always possible.

  • Clinical Counseling Training Fellows do not accept insurance.

  • Clinical Counseling Training Fellows do not offer weekend appointments or appointments after 5pm.

  • Clinical Counseling Training Fellows are only available to provide care for clients who are residing in North Carolina.

If you or someone you know is experiencing mental health emergency, please consider using any of the below crisis resources:


  • The Trans Lifeline at 877-565-8860

  • Blackline at 800-604-5841 (prioritizes BIPOC callers)

  • The Samaritans Hotline at 877-870-4673

  • The National Domestic Violence Hotline at 800-799-7233

In-Person Crisis Resources:

  • Your nearest emergency room, or any of the below:

  • Carolina Outreach Behavioral Health Urgent Care 919-251-9009 (Durham County)

  • Durham Recovery Response Center 919-510-9132

  • Triangle Springs 919-372-4318 (Raleigh/Durham)

  • Pasadena Villa 877-845-5235 (Raleigh/Charlotte)

  • Wake County Crisis Stabilization Center 984-974-4800 (Wake County)

  • Holly Hill Respond 919-250-7000 (Wake County)

A sliding scale is used to encourage people to pay according to their available resources. Those with greater financial privilege contribute more, allowing those with less access, to pay according to their means. This allows us to sustain services while making accessibility as broad as possible.

Tier 3:

  • I am comfortably able to meet all of my basic* needs

  • I may have some debt but it does not prohibit attainment of basic needs

  • I own my home or property OR I rent a higher-end property

  • I own or lease a car

  • I am employed or do not need to work to meet my needs

  • I have regular access to health care

  • I have access to financial savings

  • I have an expendable** income

  • I can always buy new items

  • I can afford an annual vacation or take time off

Tier 2:

  • I may stress about meeting my basic needs but still regularly achieve them

  • I may have some debt but it does not prohibit attainment of basic needs

  • I own or lease a car

  • I am employed

  • I have access to health care

  • I might have access to financial savings

  • I have some expendable income

  • I am able to buy some new items & I thrift others

  • I can take a vacation annually or every few years without financial burden

Tier 1:

  • I frequently stress about meeting basic needs & don’t always achieve them

  • I have debt and it sometimes prohibits me from meeting my basic needs

  • I rent lower-end properties or have unstable housing

  • I do not have a car and/or have limited access to a car but I am not always able to afford gas

  • I am unemployed or underemployed

  • I qualify for government assistance including food stamps & health care

  • I have no access to savings

  • I have no or very limited expendable income

  • I rarely buy new items because I am unable to afford them

  • I cannot afford a vacation or have the ability to take time off without financial burden

*Basic Needs include food, housing, health care, and transportation.
** Expendable Income might mean you are able to buy coffee or tea at a shop, go to the movies or a concert, buy new clothes, books, and similar items each month, etc.

Please complete the following section for yourself or if you are a legal guardian, your dependent minor.