Sliding Scale Payment Application

Instructions: Please list all household members and fill out the application to the best of your ability. If you need assistance, please ask a registration member. Please note that an application cannot be processed until the completed and signed application and supporting income documents are returned to Willapa Behavioral Health. Please be prepared to provide additional documentation if requested by WBH finance team.

Sliding Scale Payment Application

Sliding Scale Application

Maximum file size: 5MB

In order for your application to be processed, upload at least one of the three.
  • Last 3 month's paystubs (preferred)
  • Most recent year's W2
  • Social Security
  • Unemployment
  • Other income award letter

Maximum file size: 10MB

 I certify that the information on this application is true and accurate. I understand that it is my responsibility to complete the application and provide the required proof of income documentation in order to apply for discounted services, including reporting any changes of income within 30 days from the change.

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