Sliding Scale Application - Worcester Youth and Family

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 here

Head of Household

First Name(Required)

Last Name(Required)

Place of Employment(Required)

Home Address(Required)

City(Required)

State(Required)

Zip(Required)

Spouse & Dependents Under the Age of 18

Self(Required)

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.

Self +

Spouse +

Other =

Total

Income from business, self-employment, and dependents

Self +

Spouse +

Other =

Total

Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income

Self +

Spouse +

Other =

Total

GRAND TOTALS

Total Self Income +(Required)

Total Spouse Income +

Total Other Income =

Income Grand Total(Required)

Signature

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

First Name(Required)

Last Name(Required)

Signature(Required)

Date(Required)

Phone
This field is for validation purposes and should be left unchanged.