3. DIVERSUS HEALTH NETWORK SOBER LIVING FUNDING REQUEST

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Diversus Health Network
PO Box 15318, Colorado Springs, CO 80935
Phone number 719-572-6100 and fax number 719-572-6466
Email: Soberlivingapp@diversushealth.org

DIVERSUS HEALTH NETWORK
SOBER LIVING FUNDING REQUEST

E-mail Completed Sober Living Application and letter to: Soberlivingapp@diversushealth.org

Your information: All information must be entered to be considered for funding:

First Name: Client first name Last Name: Client last name

Date of Birth: Text field

Phone: Text field Email: Text field

Emergency Contact:

Name: Text field Phone: Text field Email: Text field

Relationship: Text field Ok to Contact: Checkboxes Checkboxes

SOBER LIVING ARRANGEMENTS: All questions must be answered to be considered for funding:

Where are you currently staying? Text field

How much is the rent contribution? Text field

Do you owe a balance (Check One)?

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Checkboxes Amount owed $Text field

Is this your first time in sober living (Check One)?

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If NO, what house(s) were you at? Text field

What were your dates of stay (MM/YY)? Text field

Have you been asked to leave a recovery residence (Check One)?

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If yes, why were you asked to leave? Text field

RECOVERY: All questions must be answered to be considered for funding

What is your date of last use? Text field
What is your drug of choice? Text field
Other than sober living, what steps are you taking in your recovery? Text field
What is your longest period of sobriety? Text field
How were you able to maintain your sobriety during this period? Text field
If coming from Detox, what made you decide to go to Detox? Text field

INCOME/EMPLOYMENT: All questions must be answered to be considered for funding

Are you currently working? Checkboxes Checkboxes
If not, what steps are you taking to seek employment? Text field
Do you receive disability benefits (SSI/SSDI/A&D)? Checkboxes Checkboxes
If yes, how much do you receive per month? Text field
Do you receive SNAP Benefits? Checkboxes Checkboxes
Do you have a State Valid ID? Checkboxes Checkboxes
Do you have a Valid Social Security Card or Birth Certificate? Checkboxes Checkboxes
Can you work, do chores, and do activities of daily living? Checkboxes Checkboxes

RENT: All questions must be answered to be considered for funding

Have you received funding from Diversus Health in the past? Checkboxes Checkboxes
If yes, provide the dates of previous funding: Text field
How will you pay your rent and other bills if denied funding? Text field

MEDICAL: All questions must be answered to be considered for funding

Do you currently have Medicaid or other Health Insurance (Check one)?

Checkboxes Text field

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If other, provide the name of other Health Insurance: Text field
Do you have a Mental Health Diagnosis? Checkboxes Checkboxes
If yes, provide diagnosis: Text field
Are you prescribed any Medications for this diagnosis? Checkboxes Checkboxes
If yes, list medications:

1. Text field

2. Text field

3. Text field

4. Text field

Do you take these medications as prescribed? Checkboxes Checkboxes

Are you currently working with a therapist or psychiatrist? Checkboxes Checkboxes

If yes, provide name and contact information:

Name: Text field Phone: Text field Email: Text field

Ok to Contact: Checkboxes Checkboxes

If not, are you interested in receiving treatment? Checkboxes Checkboxes

Do you have any health conditions? Checkboxes Checkboxes

If yes, list health condition(s):Text field

Are you prescribed any medications for this condition? Checkboxes Checkboxes

If yes, list medications:

1. Text field

2. Text field

3. Text field

4. Text field

Do you take these medications as prescribed? Checkboxes Checkboxes

LEGAL: All questions must be answered to be considered for funding

Are you on Probation? Checkboxes Checkboxes

If yes, provide the name and contact information of the Probation Officer:

Name: Text field Phone: Text field Email: Text field

Are you on Parole? Checkboxes Checkboxes

If yes, provide the name and contact information of the Parole Officer:

Name: Text field Phone: Text field Email: Text field

Ok to Contact: Checkboxes Checkboxes

Do you have any pending criminal charges? Checkboxes Checkboxes

Do you have any outstanding warrants? Checkboxes Checkboxes

If yes, please explain: Text field

Do you have any upcoming court dates? Checkboxes Checkboxes

If yes, provide dates: Text field

Are you a sex offender? Checkboxes Checkboxes

If yes, provide the date of the offense: Text field

If yes, do you need to register? Checkboxes Checkboxes

First Month Funding Letter Requirements

All applications must include a letter that tells us your personal story. Things that we would like to see in your letter would include your substance use history, traumatic events, and any recovery goals that you may have. We would like to know what support systems you have and any coping skills you are currently using. Please be as detailed as possible.

*So that you know, approval for funding does not guarantee placement into a specific home. All homes reserve the right to approve or deny potential residents at their discretion*

Additional Funding Letter Requirements

To be considered for funding, you must write a NEW letter and complete a NEW application. This letter will let us know why you need an additional month of funding, what progress you have made in your recovery since your last application, what has been working for you, and where you feel you could use additional help. These applications and letters MUST be sent through your house manager to be considered for additional funding.

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I support the request for additional funding.

I do not support the request for additional funding.

_____________________________________________________

House Manager/Owner Signature Date

DIVERSUS HEALTH NETWORK

Additional Resources Request

Date of request: Date First Name: Text field Last Name: Text field Date of Birth: Client birthdate

Phone Number: Client phone E-Mail: Client email

Please check the resources that you may need:

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If you do not see resources that you need listed or need additional resources, please write them in this box: Text field

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Diversus Health Network

PO Box 15318, Colorado Springs, CO 80935
Phone number 719-572-6100 and fax number 719-572-6466
Email: Soberlivingapp@diversushealth.org

Client First Name: Text field Last Name: Text field DOB: Client birthdate

Address: Client Address City: Client City State: Client State Zip: Client Zip

Phone Number: Client phone Fax Number: Client phone

I do hereby consent and authorize Diversus Health to:

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Name: All my treatment providers at:

Name: Text field Phone: Text field Email: Text field

Ok to Contact: Checkboxes Checkboxes

Name: Text field Phone: Text field Email: Text field

Ok to Contact: Checkboxes Checkboxes

Name: Text field Phone: Text field Email: Text field

Ok to Contact: Checkboxes Checkboxes

Information To Be Released

The information that can be obtained/disclosed under this authorization includes the following:

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Transmission Modes

The information may be released in:

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Purpose of the Release:

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Checkboxes: Text field

Additional Information

Please note – The records released may contain alcohol and drug abuse information and/or information about Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), and AIDS Related Complex (ARC).

Alcohol/Drug Abuse:

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I understand that:
-The requested information may not be protected from re-disclosures by the parties it is released to and is no longer protected under federal privacy laws; however, if this information is protected by the Federal Substance AbuseConfidentiality Regulation (42 CFR part 2), the party this is disclosed to may not re-disclose such information without my further written authorization provided for by state or federal law.
-Substance Use Disorder-related information can be released in the event of a bona-fide medical emergency without consent.
-Under 42 CFR Part 2, I have the right to request a list of disclosures to which disclosures have been made pursuant to the general designation
-For 42 CFR Part 2 violations, I can contact the US Attorney for Colorado at 1801 California Street, Suite 1600, DenverCO 80202, 1-303-454-0100
-Diversus Health has no control over this information after it is released and is not liable for any other disclosures.
-I may have a copy of this authorization.
-I may revoke this authorization at any time by notifying Diversus Health Medical Records in writing or by signing the revocation line of this form and returning it to Diversus Health Medical Records. Any revocation is for future releases and does not apply to any releases made before the revocation date.
-This authorization expires on Date or if left blank, two (2) years from my signature date.
-This authorization is not for the disclosure of psychotherapy notes, as Diversus Health does not maintain psychotherapy notes as part of the medical records.

Diversus Health Staff name:Text field Date: Date

Signature
Client signature (12 years of age and over)

Signature date: Date

Signature
Client representative/Legal Guardian signature

Signature date: Date