Apply for the Naturopathic Sliding Scale

To apply, fill out our simple, confidential, online patient registration form and pay a one-time fee of just $60.

If you are approved, the first appointment is $90 for 1.5 hours, and follow-up appointments are $60 per hour.

Name

First Name

Last Name

Personal Pronouns

Home Address

Phone

(###)

###

####

Date of Birth

Relationship Status

How many family members contribute to your household’s income?

How many family members are supported by your household income?

Annual household income:

If you have an annual household income greater than $100,000, you are NOT eligible for this program

Additional Financial Information

The Naturopathic Sliding Scale serves patients who cannot afford to pay current market rates for holistic health (between $100-$350 a session). We would like to ensure that people using this service are in true need of affordable holistic health care. Briefly tell us why you are in financial need of affordable naturopathic care at this time.

Monthly Rent or Mortgage Payment:

Monthly Car Payment Amount:

Monthly Student Loan Payment Amount:

Total amount of credit card debt:

Monthly average credit card payment amount:

Monthly childcare expenses:

Other Loan, Debt, Or Payment Amount:

How did you hear about us?

Anything else you would like Dr. Jones to know?

Reduced Appointment Fee Agreement

Please check each box as an acknowledgement of this agreement:

I can pay between $60 - $90 per appointment as well as the one-time $60 application fee.

I cannot afford current market rates for holistic health care ($100 - $350 per session).

I agree to not take advantage of this service if I can afford current market rates for naturopathic appointments. I understand this service is for patients in need who cannot otherwise afford to seek treatment.

Electronic Signature:

By typing your full name here you certify your agreement to the above clauses.

Date

YYYY

Time

Hour

Minute

Second

Next Steps

After you submit your registration form, you must click this link to pay the one-time $60 application fee. If you do not submit payment, we cannot process your application. After the fee is paid, we will email you with your Naturopathic Sliding Scale Member ID and information on how to make your first sliding scale appointment.

Please note that all of the information contained in this registration form is for Katherine Jones, Naturopathic Doctor, LLC administrative use only. It will never be made public under any circumstances.

Thank you for your interest in the Naturopathic Sliding Scale!

Apply for the Naturopathic Sliding Scale

To apply, fill out our simple, confidential, online patient registration form and pay a one-time fee of just $60. If you are approved, the first appointment is $90 for 1.5 hours, and follow-up appointments are $60 per hour.

Thank you for your interest in the Naturopathic Sliding Scale!

Questions about the sliding scale? Contact us below:

To apply, fill out our simple, confidential, online patient registration form and pay a one-time fee of just $60.

If you are approved, the first appointment is $90 for 1.5 hours, and follow-up appointments are $60 per hour.