Sliding Scale Fee Application

The purpose of this form is to document eligibility for our sliding scale fee program. As part of our sliding fee discount program, this form helps us determine your eligibility. Our center is required to ask you the following information and collect verification documentation regarding income, insurance status, household size. This form is valid for 12 months after the screening date. All information is kept confidential and used only for the purpose of determining program eligibility. 

Family/household members: this includes a spouse, parent that lives with you, child, and any dependents that you include on your tax return. 

Please enter each family/household members name and date of birth.

Household Income (List ALL household income for all adult household members): SNAP, loans and non-recurring, irregular payments are not included in the household income. 

Total for 12 months

PROOF OF INCOME IS REQUIRED FOR EACH ADULT MEMBER OF HOUSEHOLD WHO FILES A TAX RETURN IN THE FORM OF 2025 FEDERAL TAX RETURNS 

I affirm that the above information is true and correct.