Journey to Wellness Counseling- SFS Application

Journey to Wellness Counseling
Sliding Fee Scale Information

It is the policy of Journey to Wellness Counseling to provide essential services regardless of the patient’s ability to pay. Journey to Wellness offers discounts 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 a discount.

The discount will apply to all services received at this clinic, but not those services or equipment purchased from outside, including reference laboratory testing, drugs, x-ray interpretation by a consulting radiologist, and other such services. You must complete this form every 12 months or if your financial situation changes.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Please list all household members, including those under the age of 18.

	Name	Date of Birth
Self
Other
Other
Other
Other
Other

Type a question

	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
Total Income

Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
OFFICE USE ONLY

Patient Name:

Approved Discount:

Approved by:

Date Approved:

Verification Checklist

	Yes	No
Identification/Address; Driver's license, utility bill, employment ID, or other
Income: Prior year tax return, three most recent pay stubs or other

Identification proof of address, and Income

Cancelof
Should be Empty: