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Book Appointment
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ABOUT
Meet Our Team
Careers
BLOGS
ASSESMENT
ADHD
veteran-and-military
SERVICES
Mental Health Counseling
Maternal mental health counseling
Sports & Performance Psychology
Substance Abuse Counseling
Surviving Narcissistic Abuse
Psychiatry & Medication Management
veteran And Military
Student Counseling
Couples Counseling
Christian Counseling
CONDITIONS WE TREAT
Anxiety
Depression
OCD
PTSD
ADHD
Bipolar Disorder & Serious Mental Illness
WELLNESS TECHNOLOGY
The Theta Chamber
Neuro-Sound Support
Neuro-Stimulation Support
PATIENT RESOURCES
Insurance & Sliding Fee Program
Referral Form
FAQs
Contact Us
Book Appointment
Book Appointment
Home
ABOUT
Meet Our Team
Careers
BLOGS
ASSESMENT
ADHD
veteran-and-military
SERVICES
Mental Health Counseling
Maternal mental health counseling
Sports & Performance Psychology
Substance Abuse Counseling
Surviving Narcissistic Abuse
Psychiatry & Medication Management
veteran And Military
Student Counseling
Couples Counseling
Christian Counseling
CONDITIONS WE TREAT
Anxiety
Depression
OCD
PTSD
ADHD
Bipolar Disorder & Serious Mental Illness
WELLNESS TECHNOLOGY
The Theta Chamber
Neuro-Sound Support
Neuro-Stimulation Support
PATIENT RESOURCES
Insurance & Sliding Fee Program
Referral Form
FAQs
Contact Us
Sliding Fee Discount Program Application
Quantum Mental Health Wellness Center is committed to providing accessible, high-quality
mental health care. Our Sliding Fee Discount Program is based on household size and income.
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Please enable JavaScript in your browser to complete this form.
Full Name:
Email
*
Phone Number
Address:
City:
State:
ZIP Code:
Household Size:
Annual Household Income:
Checkboxes Household
Type of Insurance (n/a if none):
Checkboxes
Uninsured / Self-Pay
Insured
Medicaid
Medicare
Other
REQUIRED DOCUMENTATION
Pay Stubs
Tax Return
Proof of Income
Please submit copies (not originals) of the following supporting documents with this application.
Submit
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