Housing Stipend Request Form
Client Name
*
First Name
Last Name
Primary Counselor:
*
Please Select
Select your counselor here
Hannah Kidder
Rashad Hameed
Victoria Lindley
Mikare Michira
Kaonou Vue
Other
Group Name:
*
Please Select
Select your group here
Hiawatha
Dakota
Minnehaha
Cherokee
Other
Current Treatment Phase:
*
Phase 1
Phase 2
Phase 3
Phase 4
Legacy
Other
Payment
*
Please Select
Select payment
First Half of
Second Half of
Month
*
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Current Sober Residence
*
Do you have any plans to move in the next 60 days?
*
No
Yes
Not Sure
Is any other entity paying for your housing?
*
No
Yes
Who is paying?
Are you currently getting along with your housemates and/or manager?
*
No
Yes
Did you attend all scheduled group and individual sessions during the eligibility period?
*
Yes
No
Did you make up ALL hours missed during the same week you missed them?
Yes
No
How many are you short?
Acknowledgement
Eligibility is determined by treatment attendance, and 2 or more weeks of inconsistent attendance may result in your become ineligible for the housing incentive.
Missing more than two individual counseling sessions (of any time), may result in your becoming ineligible for the housing incentive.
Deducations are made from the stipend payments for missed groups taht are not made up the same week.
By checking this box, you indicate that you understand the terms of the stipend agreement.
I understand the terms
Signature
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