Sliding Scale Discount Form

It is the policy of Well Nourished LLC to provide essential services regardless of the patient’s ability to pay. We offer discounts based on family size and annual income.

Please complete the following information and email to office@wellnourishedpsych.com to determine if you or members of your family are eligible for a discount.

The discount will apply to all services received at this clinic. You must complete this form every 2 months or if your financial situation changes.

Name*

First NameLast Name

Date of Birth*

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list all household members, including those under age 18*

Rows	Name	Date of Brith
SELF
Other
Other
Other

INCOME SOURCE*

Rows	SELF	OTHER	TOTAL
Gross wages, salaries, tips, etc.
Income from business and self-employment
Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, veterans' payments, survivor benefits, pension or retirement income
Interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources

HourlyWeeklyBi-weeklyMonthly

I certify that the family size and income information shown above is correct.

Patient Name*

First NameLast Name

Signature*

Upload your 3 most recent pay stub*

Disclaimer:
This is a temporary sliding scale arrangement based on current financial circumstances. The agreed rate will be re-evaluated every two (2) months and is subject to change if your financial situation improves or changes significantly. Continued eligibility for the sliding scale will be assessed during these regular
reviews

Patient Information