Sliding Fee Program Application Form

 

Please complete the electronic form below.

 All fields marked (*) are required fields.  All information submitted on our website is private and confidential. Your treatment experience is strictly private and confidential, protected by federal and state law. 

If you need assistance in filling out our intake paperwork call 406-541-0024

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To complete the form by hand:

Please call 406-541-0024 to request a paper form be mailed to you.

You may also download this form, scan and return by

Email: referrals@wmmhc.org

or Mail to: Western Montana Mental Health Center

1321 Wyoming St, Missoula, MT  59801