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Sliding Scale Application Form - Upper Bay Counseling and Support - upperbay

Sliding Scale Application Form - Upper Bay Counseling and Support - upperbay 2026

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The document is a discounted/sliding fee application form from Upper Bay Counseling & Support Services, Inc. It collects personal and financial information from clients to determine eligibility for reduced fees based on household income and family size. The form requires details about the client, dependents, annual income sources, assets, liabilities, and extraordinary expenses. Clients must certify the accuracy of their information and may need to provide additional documentation for verification.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your client name and case number at the top of the form. This information is essential for identifying your application.
Fill in the program you are applying for, along with details about the head of household if applicable, including their place of employment and contact numbers.
List all family members under age 18, including their names and dates of birth. This helps determine your total family size.
Provide your annual household income by detailing various sources such as wages, social security, and any other income. Ensure accuracy as this will affect your eligibility for discounts.
Review the certification statement at the bottom of the form. Sign and date it to confirm that all information provided is correct.

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What is a sliding scale fee for counseling?

How does sliding scale therapy work? A sliding scale for therapy is a payment system to make therapy more accessible by adjusting the cost based on clients ability to pay. Sliding scale rates are determined by evaluating a clients income and setting fees accordingly.

What is an example of a sliding scale fee?

Example of Sliding Scale Fees The average cost of a patient visit is $500. The hospital has implemented a sliding scale fee structure for treatment. The cost per patient visit will vary from $100 to $700 based on the specific incomes of the patients. The lowest income earners pay $100 and the highest pay $700.

What does sliding scale mean in mental health?

What is a sliding scale for mental health services? A sliding scale payment system adjusts session fees based on a clients income, ensuring that those with financial constraints can still receive support.