To be considered for the sliding scale fee, the participant must have a diagnosis of dementia and this form must be completed. If you choose not to complete this form, the rate will be $15.00 per hour.
[contact-form to=’[email protected], [email protected]’ subject=’Financial Form’][contact-field label=’Participant Name’ type=’name’ required=’1’/][contact-field label=’Date’ type=’text’ required=’1’/][contact-field label=’Name of Person Completing Form’ type=’name’ required=’1’/][contact-field label=’We choose not to complete this form and pay $15.00 per hour.’ type=’checkbox’/]
Gross Monthly Income (Social Security, VA benefits, Pensions, Alimony, Estate or Trust Funds, Interest Income, Employment, SSI, Other)
[contact-field label=’Participant’ type=’text’/][contact-field label=’Spouse’ type=’text’/]
Assets (Savings, Checking, Equity/Real Estate, Stock, CD, IRA, Money Market, Cash Value Life Insurance)
[contact-field label=’Participant’ type=’text’/][contact-field label=’Spouse’ type=’text’/][contact-field label=’Total Household Expenses’ type=’text’/]
Current Monthly Medical Expenses (Prescriptions, Medicare Premiums, Insurance Premiums, Over the Counter Medications, Doctor Visits, Bills
[contact-field label=’Participant’ type=’text’/][contact-field label=’Spouse’ type=’text’/][contact-field label=’Total Medical Expenses (Participant + Spouse)’ type=’text’/]
Adjusted Monthly Income
[contact-field label=’Total Monthly Income’ type=’text’/][contact-field label='(minus) Total Household Expenses’ type=’text’/][contact-field label='(minus) Total Medical Expenses’ type=’text’/][contact-field label='(equals) Adjusted Net Monthly Income’ type=’text’/][contact-field label=’Electronic Signature’ type=’name’ required=’1’/][contact-field label=’Date’ type=’text’ required=’1’/][/contact-form]