UIRC Sliding Fee Scale Application

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We know that family building is expensive. We want individuals managing infertility to have access to affordable mental health counseling. Please apply if you feel you would benefit from reduced cost sessions and do not have health insurance or are not covered by a plan we accept. Extensions are approved on a case-by-case basis by the UIRC Clinical Committee.

Total yearly household income from all sources. *

$0-$9,999

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

$60,000-$69,999

$70,000-$79,999

$80,000-$89,999

$90,000-$99,999

$100,000 and above

Amount you have spent in the last 12 months on family building *

Phone Number *

Date of Birth *

Number of people in household. *

Other pertinent information (not required) *

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