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. 

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To complete the form by hand:

Please call 406-532-8400 to request a paper form be mailed to you.

You may also download this form, scan and return by

Email: access@wmmhc.org

or Mail to: Western Montana Mental Health Center

1321 Wyoming St, Missoula, MT  59801