Sliding Scale Application

Sliding Scale Application
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Reason for inability to pay:
(examples: Disabled, injured, homeless etc.)
Where does your current income come from?
(Examples: unemployment, disability, SSDI, SSI, Welfare, Family, Friends, Church)
How much do receive from the above sources in total per month $
Does anyone else in your household/relationship contribute to paying your bills?
If yes who and how are they related:
Monthly total household income $
What is your plan to pay for treatment if you do not qualify for the sliding scale program - what are your options?
Have you asked Probation/Diversion for voucher assistance?
We have a limited number of people allowed on our sliding scale program. Tell us about why you are a good candidate for the program:

** Please email copies/photos of a bank statement with the account number
crossed out showing your last 30 days of transactions.
Housing (Rent, Mortgage)
Child Care
Utilities
Auto Insurance
Car Payment
Credit Cards
Child Support
Student Loans
VA Payments
Other
Other Description
Total

CONDITIONS OF SLIDING SCALE PROGRAM IF APPROVED
Check each below to acknowledge your agreement
Please provide proof or documentation of your income and monthly bills. PFA will ask for some concrete proof of your situation so uploading of bank statements and paystubs here will both speed up the approval process as well as improve your likelihood of receiving these reduced fees.

File types allowed: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, jpg, jpeg, png, gif
Cancelof
By submitting this document I am attesting that all information listed above is true and accurate, if discovered otherwise I understand that I can be discharged from treatment and returned to the courts for providing false information to a court ordered treatment program.
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Should be Empty:

CONDITIONS OF SLIDING SCALE PROGRAM IF APPROVED