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:

Hotlines:

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)

First Name (Chosen) *

Last Name *

What are your pronouns?

Email *

We will be reaching out to you via email. Please confirm your understanding by checking yes. *

Yes

Phone *

May we text you to provide updates on your appointment request? We will only text you if we cannot reach you via email.

May we leave you a voicemail message? We will only call if we cannot reach you via email.

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.

Where do you fall on the Green Bottle Sliding Scale? *

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

Date of birth

Do you identify as LGBTQ+?

Do you identify as BIPOC (Black, Indigenous, Person of Color)?

What are your racial and ethic identities?

Asian

Asian American, Native Hawaiian, and Pacific Islander (AANAPI)

Bi/Multiracial

Black/African American

Indigenous/Native American/First Nations

Latin/Latin@/Latine/Latinx

Southwest Asian and North African (SWANA)/Middle-Eastern

White/European American

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Do you have preferred identities held by a therapist (e.g., gender, race)?

Briefly describe the issue you would like to work on. *

What are your preferred therapy models, techniques and/or approaches (e.g., cognitive behavioral therapy, trauma-informed, feminist)?

I understand that a commitment to weekly sessions is required to establish care. *

Yes

I understand that I must reside in North Carolina to receive care. *

Yes

I understand that appointments may be recorded. *

Yes

If you have accessibility needs (e.g., a wheelchair-accessible building), or anything else you'd like to let us know about your preferences and/or needs, please state them here.

Provide 3 Times The Client Is Available for Counseling *

How did you hear about us? *