Sliding Scale Application

Thank you for your interest in our pelvic floor physical therapy services. At Kemper Pelvic Physio, we are committed to providing accessible and trauma-informed healthcare to everyone. Our sliding scale policy is designed to ensure that individuals from all walks of life can access the care they need.

We welcome all individuals regardless of their financial situation, and encourage those who may face financial challenges to utilize this policy. Additionally, we are committed to addressing health disparities and promoting inclusivity in healthcare.

Please take a few moments for thoughtful completion of this entire form so that we can better understand your needs and provide you with the best possible care. Once completed, click the Submit button. We will review your information and reach out to you as soon as possible to discuss scheduling an appointment. We are committed to supporting you on your journey to better pelvic health and overall well-being.

Thank you for entrusting us with your healthcare needs.

How it works

Sliding Scale Tiers

There are a select number of slots available for each category below. Sliding Scale means that the rates for services vary between three payment tiers.

Consider how you fit in each of these tiers. When you fill out the form below, you'll select the category you feel is most appropriate and would also be a commitment for you. Some may not fit neatly into any individual category — please consider the closest fit for your situation.

In all cases, but especially if your situation crosses multiple categories, we will consider all responses in totality to determine eligibility.

Criterion	Tier 1	Tier 2	Tier 3
Housing	Own home in desired location or rent higher end property	Own or rent in a low- or middle-income area	Rent in a low-income area and/or need roommates
Transportation	Own or lease a vehicle, or use rideshare	Have to use rideshare or public transit	Required to use public transit or rely on others
Discretionary income	Expendable income — can buy new items, vacation, save for the future	Can plan and sometimes save, but difficult to save for the future; vacation every few years	No discretionary income; little or no travel
Healthcare affordability	Can easily afford healthcare services	Healthcare expenses are a challenge but manageable	Regularly cannot use healthcare because it's prohibitively expensive
Dependents	No dependents, or easily able to support them	Have dependents — support takes significant time and income	Have dependents and sometimes struggle to support them
Healthcare history	Good or a few negative experiences with providers — doesn't prevent you from seeking care	A few negative experiences with providers — may or may not alter seeking care	Multiple negative experiences with providers — has made you avoid seeking care
Follow-up visit	$275	$165	$85
Initial evaluation	$295	$180	$90

Prices shown above are for hourly follow-up sessions and initial evaluation visits, respectively.

Apply now

Application Form

All information is kept confidential and used only to determine eligibility and schedule your care.

Name *

Date of Birth / Age * Zip Code *

Email * Phone Number *

How did you hear about us? *

Referred by

Briefly describe why you are seeking an appointment at Kemper Pelvic Physio. * Please note how long you've been experiencing these symptoms.

Please review the Sliding Scale Table above, and choose a tier. * You'll be able to explain your reasoning below.

Please share how you came to identify that tier as most appropriate to you. *

Please describe any aspects of your identity that you feel are relevant to your healthcare experience.

What else do you want us to know?

Are there any questions we can answer for you?

Have questions before applying?

Jenna and our Client Coordinator team are happy to talk through your situation before you fill out the form. There's no pressure to apply if it isn't the right fit.

Send a message Call (404) 228-1935