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Stress & Anger Management Institute

 Sliding Scale Application

(For Group Anger & Stress Classes)

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Question 1 of 18

1. Full name:

Question 2 of 18

2. Email:

Question 3 of 18

3. Mobile phone:

Question 4 of 18

4. Time zone:

Question 5 of 18

5. Which SAMI group are you applying for?

A

Private Breaking the Anger Habit – Weekend Intensive Retreat

B

Weekly Anger & Stress Skills Group

C

1:1 Relationship & Communication Skills Coaching

Question 6 of 18

6. How would you best describe yourself right now?

A

High‑achieving professional feeling burned out

B

Parent navigating constant conflict at home

C

In a high‑conflict relationship or co‑parenting situation

D

Leader/entrepreneur needing better boundaries

E

Court-ordered

Question 7 of 18

7. How many people are in your household, including yourself, whose expenses you help cover?

A

1

B

2

C

3

D

4

E

5

F

6+

Question 8 of 18

8. What is your approximate gross monthly household income (before taxes)?

A

Under $1,500

B

$1,500–$2,499

C

$2,500–$3,499

D

$3,500–$4,499

E

$4,500–$5,499

F

$5,500–$6,499

G

$6,500+

Question 9 of 18

9. What is your approximate gross annual household income (before taxes)?

A

Under $20,000

B

$20,000–$34,999

C

$35,000–$49,999

D

$50,000–$64,999

E

$65,000–$79,999

F

$80,000–$99,999

G

$100,000+

Question 10 of 18

10. Do you currently receive any of the following? (Check all that apply.)

A

Unemployment benefits

B

Disability benefits

C

Food assistance (SNAP or similar)

D

Housing assistance

E

Medicaid / AHCCCS or similar public insurance

F

None of the above

Question 11 of 18

11. Which of the following are part of your current financial reality?

A

Recent job loss or major reduction in hours

B

Major medical or mental health expenses not covered by insurance

C

Single‑parent household

D

Caring for dependents with high needs (children, elders, disability)

E

Recent separation/divorce

F

Supporting family members financially outside your home

Question 12 of 18

12. In a few sentences, share what’s making the standard group fee feel out of reach right now.

Question 13 of 18

13. What fee range would feel stretching but sustainable for you per group session / per group cycle?

A

I can pay full fee

B

75–100% of the full fee

C

50–74% of the full fee

D

25–49% of the full fee

E

Less than 25% of the full fee

Question 14 of 18

14. If approved for a reduced rate, which options are you open to?

A

A payment plan

B

Attending a specific group time to access a sliding scale spot

C

Being placed on a waitlist if current sliding scale spots are filled

Question 15 of 18

15. Are you able to provide any of the following as a snapshot of your income?

(*Note: We will reach out privately with the next steps.)

A

Recent pay stub(s)

B

Most recent tax return

C

Unemployment or disability benefit statement

D

Social Security or pension statement

E

Other proof of income

Question 16 of 18

16. Please confirm the following:

I understand that sliding scale spots at Stress & Anger Management Institute are limited and not guaranteed.

 

A

Yes

B

No

Question 17 of 18

17. Please confirm the following:

I understand this form is used only to determine a fair rate and will be kept confidential.

A

Yes

B

No

Question 18 of 18

18.Please confirm the following:

I understand my rate may be revisited if my financial situation significantly changes so that access can remain available to others in the community.

A

Yes

B

No

Confirm and Submit