Sliding Scale Application

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Use tab to navigate through the menu items.

First name

Email

Do you have health insurance?

Household size

Last name

Phone

Annual household income

I understand that I must provide proof of eligibility to qualify for the sliding fee scale discount.

Do you qualify for any of the following programs?

SNAP

WIC

Free/Reduced School Lunch

TANF

Disability Benefits

Thank you!

We’ll be in touch soon.

7612 W. Avenida Norte

2 ° piso

Elmwood Park, Illinois 60707

Teléfono: 708-240-3874

Fax: 773-598-8022

First Name

Email

Client's age

Where would you like services? * Obligatorio

Perennial SLP Office

In-Home

Daycare/Preschool

Private School

Other (library, park, etc.)

Last Name

Client's name

What are your concerns?

Insurance Type * Obligatorio

BCBS PPO

UHC PPO or UMR PPO

Aetna PPO

Other

Thanks for submitting!

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