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The Roots Foundation
Thank you for your interest in our financial assistance program. Please complete the form below to be considered for support. All information will be kept confidential.
Personal Information
Name
First
Last
Phone
Email
Date of Birth
MM slash DD slash YYYY
Address
City
State
ZIP / Postal Code
Family Members
Name
Relationship
Date of Birth
Gender
Actions
Edit
Delete
There are no
Family Members.
Add Family Member
Maximum number of family members reached.
Household Information
No. of People in Household
Total Household Income
Employment Status
Employed
Unemployed
Student
Retired
Other
Are you currently receiving financial assistance?
Yes
No
Please specify. _________________________________
Insurance & Coverage
Do you have health insurance that provides out-of-network reimbursement?
Yes
No
Service Request Details
Service(s) being requested (or recommended by provider):
Estimated Cost of Treatment
Frequency
Per Session
Weekly
Monthly
Not Sure/Other
Assistance Desired:
Partial Coverage
Full Assistance
Additional Information
Please provide any additional details or circumstances relevant to your application (financial hardship, specific circumstances, reason for need for support at this time):
Agreement
Agreements & Acknowledgments
(Required)
I understand that the nonprofit will reassess the applicant's needs annually.
I agree to contact the organization if my financial circumstances change. Ongoing support will be re-evaluated annually, and I understand I will need to re-apply at that time, regardless of when my support started.
I certify that all information provided is accurate to the best of my knowledge.
I understand that receipt of financial assistance is based on my full participation in treatment services and goals as developed together with my (and/or my child’s) treatment provider.
I understand that I will need to sign a basic release of information form to allow The Roots Foundation to coordinate with my service provider/organization regarding my participation in treatment services and follow through with treatment plan and recommendations.
I agree to the privacy policy.
Signature
Date
MM slash DD slash YYYY
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