+1 219-477-5646

Client Resources

Forms, fee scale, pay online and more...

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New Client Forms

adobe_pdf_icon New Client Intake Form | Start completing your paperwork now to make your first visit smoother.

adobe_pdf_icon Minor Form | This form must be completed before we can treat a minor [under age 18] patient.

adobe_pdf_icon Privacy Policy | All of our clients are required, by law, to read and sign our privacy policy.

Current Client Forms

adobe_pdf_icon Records Release Consent | We respect your privacy.  In order to share your confidential information with anyone, we must have your written consent on file.

adobe_pdf_icon Sliding Fee Scale Form | This document provides sliding fee scale in addition to Sliding Fee Agreement between client and counselor/Family Concern Counseling.

adobe_pdf_icon Scholarship Application | In order to qualify for our Scholarship Program, you must first apply. Upon approval of your application, call 219-477-5646 for an appointment to determine the scholarship amount.

Payment Information

Credit or Debit Card 

Select the PayPal Icon to make your payment.

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Personal Check

There are two options if you wish to pay by Personal Check

1.) You can drop off your check, in person, during normal business hours.

2.) You can mail your Personal Check to:

Family Concern Counseling
Attn: Payment Department
2004 Valparaiso Street
Valparaiso, IN  46383

Cash Payments

Cash Payments are accepted in person only (please do not mail cash)

Cash Payments can be made Monday through Friday during normal business hours. [9am—5pm M—F]

Sliding Fee Scale - For self-pay clients

Sliding Fee Schedule 

Individual, Couple, or Family Counseling

This schedule reflects the charge for a 45 minute counseling session based on monthly household income.

Monthly Household Income 

1-4 Dependents 

5 or more Dependents 

Over $6,000 

$130 

$95 

$5,000-5,999 

$90 

$85 

$4,000-4,999 

$80 

$75 

$3,000-3,999 

$70 

$65 

$2,000-2,999 

$60 

$55 

$1,000-1,999 

$50 

$45 

Under $1,000 

$30 

$35

adobe_pdf_iconSliding Fee Scale — PDF Version

FCC Quick Facts

 FCC Quick Facts  | A quick synopsis of our agency.

adobe_pdf_icon Download and Install Adobe Reader to view and print forms.

After installing Adobe Reader, select links to download or Right Click and Save As to your computer’s documents folder. You can type your information right onto the form or print it out and complete the old fashioned way and bring it with you to your first/next session.

Please call 219-477-5646 if you have any problems or questions regarding these forms.