Sliding Fee Discount Application

Sliding Fee Discount Application
Children's Home Counseling Services (CHCS) offers a sliding scale discount program for clients and their families who may qualify for assistance with the cost of services. CHCS will base program eligibility on annual income, situation, and family size. CHCS does not discriminate based on age, gender, race, sexual orientation, gender identity, gender expression, religion, disability, or national origin.

The Federal Poverty Guidelines are used to update the sliding fee schedule annually to determine discounted services.

Please note: Application does not guarantee approval. Hybrid options may be offered. If you have insurance, approval will be based on allowable with insurance for services and only actual payment will be reported to insurance.
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Household
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please list names and birthdates for all members of the household

Reason for applying for sliding fee/subsidy?

Low incomeCannot pay all of balance owedJob loss/changeChange of insuranceSignificant debtMultiple children receiving servicesDivorceOther
If other, please list here.
Please explain more about your situation

Which of the following plans would meet your needs?
Payment Plan/Sliding Scale. [this plans works with your financial situation and insurance.] Please provide the $ amount you can pay for services.
The dollar amount I can pay is $ add dollar amount. I can pay on the add a day of the month of every month.
How long do you need the payment plan in place?
Partial Subsidy [waiver of some costs for services, client balance] Please provide the $ amount you can pay for services.
The dollar amount I can pay is $ add dollar amount. I can pay on the add a day of the month of every month.
How long do you need the payment in place?
Full Subsidy [waiver of all costs for services]

Annual Household Income

Please fill out for both self and spouse. [Mandatory Information]
Gross wages, salaries, tips - SELF
Income from self-employment - SELF
Gross wages, salaries, tips - OTHER PARENT/SPOUSE
Income from self-employment - OTHER PARENT/SPOUSE
Optional Informational
Monthly Debt - SELF
Monthly Debt - OTHER PARENT/SPOUSE

Supporting documents can include Copies of Tax returns, W-2 form or other information verifying annual total household income is required. If no supporting documents are included with the application, it will be returned to the applicant.

Self-employed individuals will be required to submit detail of the most recent three months of income and business expenses. In the case of two parent households, each parent is required to provide proof of income.

Agreement
If awarded a discounted rate, the responsible party will be notified in writing. Discounted rates are based solely on income, family size and Federal Poverty Guidelines. There may be a balance for each visit if not covered by insurance. If there is a financial hardship that makes paying any discounted rate difficult, the responsible party may contact Warm Springs Counseling Center about a payment plan or other options. Clients approved for a subsidy will have a limit on the amount of sessions to be determined by the clinician.

I agree to all of the Sliding Fee Discount Program requirements. I understand that providing false information of any kind will result in immediate termination of this agreement and I will be required to pay the agency's full rate for each date of service provided. I certify that the family size and income information shown above is correct.
Responsible Party Name*
Responsible Party Signature *

Clear
Date*

MonthDayYear
Date
Should be Empty:

Annual Household Income