Family Therapy Center
Client'Name:
Address:
Birthdate:
Gross'Annual'Income'(i.e.,'prior'to'taxes):
Number'of'individuals'provided'for'by'the'
gross'annual'income'listed'above:
Client Signature Date
Type%of%income%verification%used%(attach%a%photocopy%of%the%client's%proof%of%income):
Lipscomb%University%Student%(exempt)
Tax%Form%1040
Check%Stub
Other%(must%be%approved%by%the%clinic%director)
Established%fee%per%clinical%hour: !
Therapist Signature Date
Date
Clinic Director Signature (if necessary for approval)
"#$%&'()*+%)%#$,$-#%)./+)'0%)(#$1$&,).%%)(2*#%)-3).$##$&,)/4')'0$()./+5)*&1)6+/7$1$&,)6+//.)/.)$&2/5%)8%9,9:)20%2;)('4-:)
<*=)>/+5)?@A@B9)"#$%&'()4&*-#%)'/)6+/7$1%)6+//.)/.)$&2/5%)*+%)20*+,%1)'0%)5*=$545).%%)6%+)(%(($/&)8$9%9:)!C@9@@)
6%+)2#$&$2*#)0/4+B9)D$6(2/5-)E&$7%+($'3)('41%&'()*+%)%=%56').+/5)*##).%%(9)
Proof'of'Income'Verification
F3)($,&$&,)-%#/G:)H)2%+'$.3)'0*')'0%)$&./+5*'$/&)H)6+/7$1%1)/&)*&1)$&)2/&&%2'$/&)G$'0)'0$()./+5)$()'+4%:)*224+*'%:)*&1)
2/56#%'%9)H)4&1%+('*&1)'0*')*&3)20*&,%()$&)53)$&2/5%)G$##)+%(4#')$&)*)+%*((%((5%&')/.)53)(#$1$&,)(2*#%).%%)*&1)'0*')
$')$()53)+%(6/&($-$#$'3)'/)&/'$.3)53)'0%+*6$(')$&'%+&)/+)/'0%+)D$6(2/5-)>*5$#3)<0%+*63)"%&'%+).*24#'3)/+)('*..)$.)'0%+%)
*+%)*&3)20*&,%()'/)53),+/(()*&&4*#)$&2/5%9)H)4&1%+('*&1)'0*')'0%)D$6(2/5-)>*5$#3)<0%+*63)"%&'%+)+%#$%()/&)2#$%&')
.%%()$&)/+1%+)'/)/..%+)*../+1*-#%)(%+7$2%()'/)2#$%&'()$&)&%%19)I11$'$/&*##3:)H)4&1%+('*&1)'0*')H)5*3)+%J4%(')*&)
*#'%+&*'%)6*35%&')(20%14#%)-3)(4-5$''$&,)*)K#$1$&,)>%%)K2*#%)I1L4('5%&')I..$1*7$')'/)53)'0%+*6$('9))
______________________________________________________
________________________________________
The bottom portion of this form is to be completed by Lipscomb Family Therapy Center staff.
If%applicable,%explain%why%the%Tax%Form%1040%or%Check%Stub%was%not%used%for%verification:
______________________________________________________
________________________________________
______________________________________________________
________________________________________
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