TCS

Insurance Information
Do you have insurance?
How many plans are you under?
Primary Insurance Carrier
Primary: Subscriber ID
Upload a photo of the front and back of your insurance cards

Cancelof
Secondary Insurance Carrier
Secondary: Subscriber ID
Secondary: Upload a photo of the front and back of your insurance cards

Cancelof
Tertiary: Insurance Carrier
Tertiary: Subscriber ID
Tertiary: Upload a photo of the front and back of your insurance cards

Cancelof
Any other Insurances please provide their information below.

Household Information:
To help us determine the discount that best fits your household, please list everyone who lives in your home, including the head of household (HOH), spouse, and dependents.

Having this information ensures we can give you the most accurate discount available for your situation.
How many people are in your household?
Spouse and Claimed Dependents
Spouse Full Name:

First NameMiddle InitialLast Name
Spouse: Date of Birth:

MonthDayYear
Date
Dependent #1 - Full Name:

First NameMiddle InitialLast Name
Dependent #1 - Date of Birth:

MonthDayYear
Date
Dependent #2- Full Name:

First NameMiddle InitialLast Name
Dependent #2- Date of Birth:

MonthDayYear
Date
Dependent #3 - Full Name:

First NameMiddle InitialLast Name
Dependent #3 - Date of Birth:

MonthDayYear
Date
Dependent #4 - Full Name:

First NameMiddle InitialLast Name
Dependent #4 - Date of Birth:

MonthDayYear
Date
Dependent #5 - Full Name:

First NameMiddle InitialLast Name
Dependent #5 - Date of Birth:

MonthDayYear
Date
Dependent #6 - Full Name:

First NameMiddle InitialLast Name
Dependent #6 - Date of Birth:

MonthDayYear
Date
Dependent #7 - Full Name:

First NameMiddle InitialLast Name
Dependent #7 - Date of Birth:

MonthDayYear
Date
Dependent #8 - Full Name:

First NameMiddle InitialLast Name
Dependent #8 - Date of Birth:

MonthDayYear
Date
Other Dependents - Full Name + Date of Birth

Required Documentation
**APPLICATION CANNOT BE PROCESSED WITHOUT THIS INFORMATION**
Driver's License or State Issued ID

Applicant/Responsible Party's Driver's License or State Issued ID
Cancelof
Applicant/Responsible party's proof of address: utility bill, statement or letter with your/responsible party's name and address

Cancelof
Proof of entire household income for the last 2 months, prior year tax return, SSI Letter OR other information verifying income.

Cancelof

IF APPLICATION IS APPROVED
- You are responsible for the discounted amount at the time of each appointment.
- Failure to pay your responsible amount may result in your sliding fee scale being discontinued.
- No-show and late cancellation fees still apply and it is not eligble for discount.
Please note: If the application is not complete or incorrect, Tueller Counseling will attempt to contact the applicant. If no response is received within 10 business days, the application will be void and a new application will be required with updated documentation.
ESTIMATED DISCOUNT: Does Not Qualify

Note: Continue to submit the application for further review.
Acknowledgement and Signature
Signature
Date

MonthDayYear
Date
Should be Empty:

Sliding Fee Discount Application