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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 of Applicant
(Required)
First
Last
Who are you Requesting Support For?
(Required)
Myself
My Child
My Spouse
Other Family Member
Select all the apply. If you selected more than yourself, please use the section below to "Add Family Member".
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
(Required)
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
(Required)
Total Household Income
(Required)
Average Monthly Expenses (Bills, Medical, etc.)
(Required)
Employment Status
(Required)
Employed
Unemployed
Student
Retired
Other
Are you currently receiving financial assistance?
(Required)
Yes
No
Please specify. _________________________________
Insurance & Coverage
(Required)
Do you have health insurance that provides out-of-network reimbursement?
Yes
No
Service Request Details
Service(s) being requested (or recommended by provider):
(Required)
Estimated Cost of Treatment
(Required)
Frequency
(Required)
Per Session
Weekly
Monthly
Not Sure/Other
Assistance Desired:
(Required)
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):
(Required)
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
(Required)
Date
(Required)
MM slash DD slash YYYY
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