Discounted/Sliding Fee Application

It is the policy of Improving Lives Counseling Services, Inc., to provide essential services regardless of the patient’s ability to pay. Discounts are offered based upon family income and size. Please complete the following information 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, but not those services which are purchased from outside, including referrals made to any professional outside of our agency. In the hope that your financial situation improves, discounts only apply for six months after the time of approval. This form must be completed every six months. Please inquire with our office if you have questions.

I certify that the family size and income information shown above is correct. Copies of tax returns, pay stubs, and other information verifying income may be required before a discount is approved.