Discounted/Sliding Fee Application

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.
Name*

First NameMiddle Name/NamesLast Name
DOB*
Age*
Social Security Number
Marital Status

Never MarriedMarriedSeparatedDivorcedWidowed
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Secondary Phone Number
Email Address*
Place of Employment*
Household
Total Number of Household Members Including Yourself
Please list spouse and any family members living in household
Name:
Relationship:
Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Name:
Relationship:
Dependent Date of Birth:

MonthDayYear
Date
Total Annual Income
Please enter your annual income for all income types. To calculate your annual income, multiply your hourly wage by the number of hours you normally work in one week. Multiply that number by 52. Example: $10/hour x 30 Hours = $300 x 52 = $15,600. To calculate monthly income, like Child Support, calculate the amount per month times 12. Example: $1000/month x 12 = $12,000.

	Self	Spouse	Other
Gross Wages, Salaries, Tips, etc.
Social Security, Pension, Annuity, and Veteran's Benefits
Alimony, Child Support, Military Family Allotments
Income from Business Self Employment, and Dependents
Rent, Interest, Dividend, and Other Income

Please attach the following documentation:
Identification (Driver's License or Other Photo ID, Utility Bill, Birth Certificate, etc.)*

Cancelof
Income (prior year tax return, 3 most recent paystubs, etc.)*

Cancelof
Insurance Cards (if also filing insurance) so ILCS can verify your insurance provider allows discounted fees

Cancelof
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.
Signature*
Clinician you are/will be seeing so they can be notified
Calculation Wages
Calculation SSI
Calculation Alimony
Calculation Self Employed
Calculation Rent
Calculation Total
Should be Empty:

Discounted/Sliding Fee Application

Household

Total Annual Income

Please attach the following documentation: