Client Financial Assistance

Our heart is to always make our counseling and coaching services available to everyone.

It is the policy and heart of The Love Factor, to provide our essential services regardless of the Client’s ability to pay. Financial assistance and scholarships are offered based upon family income and size. Please complete the following information to be submitted to our financial assistance team to determine if you or members of your family are eligible for financial assistance. Any assistance will apply to all services received at Love Factor, but not those services which are purchased from outside, including referrals made to any professional or organization outside of Love Factor. In the hope that your financial situation improves, assistance and/or discounts usually are effective for six months after the time of approval. This form must be completed every six months. Please inquire with our admin team if you have any questions regarding financial assistance.

Client Financial Assistance

Primary Client General Information

Name(Required)

First Middle Last

Date of Birth(Required)

SSN(Required)

Last 4 Digits Only

Sex(Required)

Email Address(Required)

Spouse's General Information

(if applicable)

Name

First Middle Last

Date of Birth

SSN

Last 4 Digits Only

Sex

Email Address

Client's Address & Contact Information

Address(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status(Required)

Primary Phone Number(Required)

Primary Phone Number Type(Required)

Secondary Phone Number (Spouse's)

Secondary Phone Number Type

Client's Place of Employment(Required)

Client's Length of Employment(Required)

Household & Income Information

Household Children(Required)

Please enter a number from 0 to 20.

How many children do you have under the age of 18 in your household?

Household Dependents(Required)

Please enter a number from 0 to 20.

Do you have any other sole dependents living in your home that are not a child? If so, how many?

Self(Required)

Gross Wages, Salaries, Tips, etc.

Spouse

Gross Wages, Salaries, Tips, etc.

Other

Gross Wages, Salaries, Tips, etc.

Self(Required)

Social Security, Pension, Annuity, and Veteran’s Benefits

Spouse

Social Security, Pension, Annuity, and Veteran’s Benefits

Other

Social Security, Pension, Annuity, and Veteran’s Benefits

Self(Required)

Alimony, Child Support, Military Family Allotments

Spouse

Alimony, Child Support, Military Family Allotments

Other

Alimony, Child Support, Military Family Allotments

Self(Required)

Income from Business Self Employment, and Dependents

Spouse

Income from Business Self Employment, and Dependents

Other

Income from Business Self Employment, and Dependents

Self(Required)

Rent, Interest, Dividend, and Other Income

Spouse

Rent, Interest, Dividend, and Other Income

Other

Rent, Interest, Dividend, and Other Income

Total Income

Client Financial Assistance

Our heart is to always make our counseling and coaching services available to everyone.