Worcester Youth and Family Counseling Services, Inc. Logo
410 641-4598

Sliding Scale Application

It is the policy of Worcester Youth and Family Counseling Services to provide essential services regardless of the patient’s ability to pay. Discounts are therefore offered based on family size and annual income. Please complete the following information and return to the front desk to determine if you or members of your family are eligible for this discount. The discount will apply to all counseling services received at this clinic. This form must be completed every 12 months or if your financial situation, and/or insurance situation changes.

You may also download the print version of the application form.


Thank you for your submission.

Head of Household

Please correct your Head of Household, First Name.

Please correct your Head of Household, Last Name.

Please correct your Place of employment.

Please correct your Home Addresss.

Please correct your City.

Please correct your State.

Please correct your Zip.

Spouse and Dependents under the age of 18

Self

Please correct your Name.

Please correct your Date of Birth.

Spouse
First Dependent
Second Dependent
Third Dependent
Fourth Dependent
Fifth Dependent

Annual Household Income

Note: Copies of tax returns, pay stubs, or other information verifying income may be required before a discount is approved.

Gross wages, salaries, tips, etc.
+
+
=
Income from business, self-employment, and dependents
+
+
=
Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income
+
+
=

GRAND TOTALS
+

Please correct your Total Self.

+
=

Please correct your Grand Total.

Signature

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

Please correct your First Name.

Please correct your Last Name.

Please correct your Signature.

Please correct your Date.

Close

Your browser is out-of-date!

Update your browser to view this website correctly.

Get More Information