UA-137568772-1

Sliding Scale Fee & Application


At Country Crossroads Counseling, no one will be denied access to services due to inability to pay; and there is a discounted/sliding fee schedule available based on family size and income. The sliding fee scale applies to patients without health insurance.


Country Crossroads Counseling will base program eligibility on a person's ability to pay and will not discriminate on the basis of age, gender, race, sexual orientation, creed, religion, disability, or national origin.  No one is refused service because of lack of financial means to pay so long as they complete the program requirements and are found eligible in the application process.


Click the link below to enter your information and we will be in contact with you!

Be sure to complete Monthly/Annual Expense Worksheet and have your two most recent tax returns.   Further income documentation such as last two monthly bank statements and the two most recent pay stubs may be required in some circumstances.

As mandated by federal rules governing FQHC’s,

to qualify for the sliding fee program patients must: 

• Complete the Sliding Fee Scale Eligibility Application form (includes information on all household members)

• Provide the required proof of income for all household members

• Patients cannot receive the sliding fee discount until they have completed all of the required forms and submitted all of the required documents and have been enrolled.

Sliding Fee Discount Program Procedure

Discounted/Sliding fee Application

Download the Monthly/Annual Expense Worksheet

View the Sliding Scale Schedule