Please complete the following form to obtain your self-pay estimate. Please note this is an ESTIMATE ONLY. Verification of income will be completed with your therapist. Name: Email Address: People in household: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Please indicate how many people are in your household. Annual Household Income : Choose income More than $67,950 Between $54,630 and $67,950 Between $40,770 and $54,630 Between $27,180 and $40,770 Between $13,590 and $27,180 Less than $13,590 Answer the question below: Is seven < than nine? (true/false)