COVID-19 FINANCIAL IMPACT QUESTIONNAIRE (COVID-FIQ) Your Name(Required) First Last Your Email(Required) Enter Email Confirm Email Today's Date(Required) MM slash DD slash YYYY 1. Are you a current client?(Required)NoYesPlease enroll in therapy before completing this form.1a. When was your first counseling session?(Required) MM slash DD slash YYYY 1b. What is your current price per session?(Required)Please enter a number from 0 to 150.1c. Who is your current counselor?(Required) Matt Anderson Steve Baker Stacy Blassingame Laura Brackett Kaitlyn Brown Cortney Dollens Sarah Evergreen Jordan Ferguson Rachel Hagan Emily Horning Ben Koenig David Lawson Ron Laney Nicole Neace Nadiia Petrenko Zach Polk Danielle Silver Lauren Thayer NOTE: If you have more than one counselor, please select each counselor you are currently working with.2. How has COVID-19 impacted your financial situation? Please be as concrete and descript as possible. (for example: “I am a server, and COVID-19 forced my restaurant to shut down and lay us off. I do not have unemployment insurance and my only source of income is from my savings, which represents about 3 months worth of expenses. I am applying for other jobs.”)(Required)Additional Specific Questions(You may have answered some of these in your description above, but please answer again here):3. What was your most recent job industry and role?(Required)(For example: "I worked in hospitality as a bartender.")4. Did you lose your most recent job (the job from question 3)?(Required)NoYes4a. Have you been notified that your job is being terminated / suspended?(Required)NoYesPlease explain the nature of your request if you have neither lost your job nor been notified that it is being terminated or suspended -- please be as concrete and descript as possible.(Required)5. What is your current source of income/How are you currently paying your bills? Please include any unemployment, severance, or **any** other/additional external source you are using.(Required)6. Considering your current price point, what is the percent reduction that would best represent your ability to pay? (NOTE: Given the volume of needs we are trying to address, please be honest and only request what you need. A lot like TP!!)(Required)10%20%30%40%50% or Greater7. Change, Inc. may eventually be forced to move all of its in-person sessions online. If so, are you willing to continue your sessions online? (If no, please explain)(Required)NoYesAccuracy and Time-limited Accommodation Attestation(Required) The above information is accurate and reflects my current financial situation. I understand that Change, Inc. is using this information exclusively as part of its response to COVID-19. I understand that a decision on Change, Inc.’s behalf to provide financial accommodations will be time-limited and expire in the future, at which point its standard payment structure will apply.Timeliness of Response Understanding(Required) I understand that Change, Inc. will endeavor to complete its consideration of my COVID-19-related financial situation within 3 business days, but that it may take them longer depending on the volume of requests.Digital Signature(Required) By giving my typed full name above as a digital signature, I certify the truthfulness of my responses above and submit my request to be considered for financial accommodations as a result of my COVID-19-related financial situation. CAPTCHA Δ
