Roots Wellness
Center
(612) 289-5656
info@rwc-mn.com
393 N Dunlap St, Ste #300, St Paul
About Us
Our History
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Our Name Change
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Services
Mental Health Therapy
ARMHS Services
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Roots Outpatient Treatment
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Programs
Hennepin County Be@School
Hennepin In-Home Recovery Pilot
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Make a Referral
Housing Stipend Update & Payment Request
CLIENT, GROUP & PHASE INFO
Client Name:
*
First
Last
Primary Counselor:
*
Select your counselor here
Hannah Kidder
Rashad Hameed
Victoria Lindley
Mikare Michira
Kaonou Vue
Other
Group Name:
*
Select your group here
Hiawatha
Dakota
Minnehaha
Cherokee
Other
Current Treatment Phase:
*
Phase 1
Phase 2
Phase 3
Phase 4
Legacy
Other
HOUSING PROVIDER & PAYMENT INFO
NOTE: 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 payment
First Half of
Second Half of
Month
*
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Current 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 STATUS
Did 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 TERMS
Acknowledgement
*
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:
*
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Minnesota CarePartner/Roots Recovery is now
Roots Wellness Center
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