PRICING STRUCTURE ADJUSTMENT CONSIDERATION (PSAC) Request form Pricing Structure Adjustment Consideration (PSAC) request form Name(Required) First Last Today's Date(Required) MM slash DD slash YYYY Email(Required) Phone(Required)Your Therapist(Required)Anderson, MatthewBaker, SteveBlassingame, StacyBrackett, LauraBrown, KaitlynDollens, CortneyEvergreen, SarahFerguson, JordanHagan, RachelHorning, EmilyKoenig, BenLaney, RonLawson, DavidNeace, NicoleNetzer, AnnPetrenko, NadiiaPolk, LeahPolk, ZachSilver, DanielleThayer, LaurenLength of time you have been a client at Change, Inc.(Required)Less than 12 Months (Less than 1 year)12-23 Months (1 year to 1 year 11 months)24-35 Months (2 years to 2 years 11 months)36 months or greater (3 years or greater)Current Price Point(Required)Price Point with Increase (Auto-calculates)Help us understand your need for special consideration regarding our Pricing Structure Adjustment. Please be as concrete and descriptive as possible.(Required)PSAC request form Consent & Disclosures(Required) I agree to the following statements.1. The above provided information is accurate and reflects my current financial situation and felt needs. 2. I understand that Change, Inc. may be unable to provide financial accommodations for me. 3. I understand that Change, Inc. has provided this form in effort to give me time to adjust to the new pricing structure. As such, I understand that any decision on Change, Inc.’s part to provide financial accommodations to me is time-limited (typically 60-days or less) and will expire in the future, at which point its new adjusted pricing structure (+$10) will apply. 4. I understand that Change, Inc. will endeavor to complete its consideration of my PSAC request form within 5 business days, but that it may take them longer depending on the volume of requests. Digital Signature(Required) By typing my full name below as a digital signature, I certify the truthfulness of my responses above and submit my PSAC request form to be submitted.Digital Signature: Please Type Your Full Name(Required) CAPTCHA Δ
