Housing Stipend Request Form : Roots Wellness Center

CLIENT, GROUP & PHASE INFO

Client Name:*

First Last

Primary Counselor:*

Group Name:*

Current Treatment Phase:*

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*

Month*

Current Sober Residence:*

Move in Date:*

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:*

Housing Stipend Update & Payment Request

CLIENT, GROUP & PHASE INFO

HOUSING PROVIDER & PAYMENT INFO

ATTENDANCE STATUS

ACKNOWLEDGEMENT OF HOUSING STIPEND TERMS