Sliding Scale Declaration

Complete this declaration to access sliding scale fees. A staff member will process your declaration within 2 business days and provide you a coupon code based on your need (discounts range from 10-20%).

This information is confidential and will be used only for the purposes of assessing your financial need. This information will will be managed in accordance with our privacy policy.

Name

First Name

Last Name

Eligibility

Do you have access to third party insurance benefits? (blue cross, manulife, greenshield, etc.)

Are your benefits used up for the year?

What month do your benefits renew? Sliding scale declarations are only valid for the calendar year they are completed in. Enter n/a if you have no benefits.

Green Bottle Model of Financial Privledge

The Green Bottle Model is a way of assessing a person's financial need. Please answer the questions below to determine where you fall on our sliding scale. Feel free to google this model for a visual representation of the green bottle.

I frequently stress about meeting my basic needs, I have debt that prohibits me from meeting my basic needs, I rent a lower end home or have unstable housing, I do not have a car or if I have a car, I cannot always afford gas, I have no or very limited expendable income, I rarely buy new items, I qualify for government assistance, I cannot take vacations and have no access to savings.

I may stress about meeting my basic needs, but always achieve them, I have some debt but it doesn't interfere with meeting my basic needs, I own or lease a car, I might have access to financial savings, I have some expendable income, I can buy some new items and thrift others, I can take a vacation annually or every few years without financial burden, I am employed.

I am comfortable and able to meet my basic needs, I may have some debt that that does not interfere with meeting my basic needs, I own a home or rent a higher end property, I own or lease a car, I am employed or do not need to work, I have access to savings, I have expendable income, I can always buy new items, I can take a vacation or time off annually without financial burden.