Pay-What-You-Can (PWYC) Form Use this form to estimate the price of a session. Click 'Save' to include this information in your contact request.. Total monthly household income (after taxes and deductions): Number of adults: Number of children (under 18): Do you receive SNAP benefits? Select Yes No Who provides your insurance? Select Employer-Provided Medicaid / Medicare Self-Insured / Marketplace Uninsured / Not Applicable Rent / mortgage payment: Minimum debt payments: Your estimated* payment for one session would be: Save *Legal Disclaimer: This form is for estimation purposes only and is not an offer to provide services at this rate. Subject to verification of income and expenses. Actual fee to be determined in consultation with provider.