Housing Stipend Request Form Housing Stipend Update & Payment Request CLIENT, GROUP & PHASE INFOClient Name:* First Last Primary Counselor:*Select your counselor hereHannah KidderRashad HameedVictoria LindleyMikare MichiraKaonou VueOtherGroup Name:*Select your group hereHiawathaDakotaMinnehahaCherokeeOtherCurrent Treatment Phase:* Phase 1 Phase 2 Phase 3 Phase 4 Legacy Other HOUSING PROVIDER & PAYMENT INFONOTE: We pay your residence twice per month. You request a payment for the NEXT two weeks, based on the PREVIOUS two weeks' attendance. Example: On the 25th of February, you will request payment for the first half of March based on your attendance the last two weeks of February.I am requesting payment for the Payment*Select paymentFirst Half ofSecond Half ofMonth*Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberCurrent Sober Residence:* Move in Date:* MM slash DD slash YYYY Do you have any plans to move in the next 60 days?* No Yes Not Sure Is any other entity paying for your housing?*Example: GRH, Probation, Foster Care No Yes Who is paying? Are you currently getting along with your housemates/manager?* No Yes ATTENDANCE STATUSDid you attendance all scheduled group and individual sessions during the eligibility period?*Eligibility period example: Payment: March 1-15th: Eligibility Period: Last 2 Full Weeks of February Yes No Did you make up ALL hours missed during the same week you missed them? Yes No How many are you short? ACKNOWLEDGEMENT OF HOUSING STIPEND TERMSAcknowledgement* By checking this box, you indicate that you understand the following terms of the stipend agreement:1. Eligibility is determined by treatment attendance, and 2 or more weeks of inconsistent attendance may result in your becoming ineligible for the housing incentive. 2. Missing more than two individual counseling session (of any type), may result in your becoming ineligible for the housing incentive. 3. Deductions are made from stipend payments for missed groups that are not made up the same week. Type Your Name as a Signature Here:*
