Secure Documents Form
To send us documents (e.g. recent paystubs), please complete this form. When sending photos of documents, you may find it easiest to complete this form on your smart phone. You may
call us at (914) 533-4950
with any questions.
Your Email Address
Your Phone Number
Are you applying for our sliding scale?
What is your marital status?
Married / partnership
Divorced / separated
What is your living status?
With partner / spouse
With family member
What are your monthly housing expenses?
How many homes do you and / or your partner / spouse own?
What is your work status?
Employed / salaried / independent
What is your profession?
When did you become unemployed?
Do you own any assets such a savings, real estate, stocks / funds (excluding retirement funds) with a value greater than $25,000?
Please choose between one and ten document files to send us at once.
Please choose between one and ten document files containing your
most recent three months of paystubs and / or bank statements
Please describe the content of your document(s) in a few sentences.
Feeling Good Psychotherapy LCSW PLLC
235 Main Street • Suite 520 • White Plains, NY 10601
380 Lexington Avenue • 17th Floor • New York, NY 10168
160 Broadway • Suite 1204 • New York, NY 10038