Treatment Application and Information for Scholarship and Self Pay Patients

ENSO Recovery has been awarded monies for the treatment of uninsured individuals suffering from substance use and comorbid disorders. These monies will be distributed according to client need and client motivation for the duration of a client’s participation in their treatment plan.  Clients may be terminated if they fail to adhere to the treatment plan they develop with their clinician.

Clients are expected to seek employment once stabilized on their medication and may be asked to provide documentation of their employment search. It is recommended that they keep a record of employers contacted, date of contact, position applied for and the type of contact – in person, telephone, online application or resume drop off.

Eligibility:

  • Uninsured with no other source of income.
  • Motivated to be in treatment and change their life. Medication only as a motivation for entering treatment will eliminate applicants for consideration
  • Complete a Financial Affidavit Form with an ENSO Clinician. (Complete Form Below)
  • Commit to attending all groups and individual therapy sessions.
  • Commit to participate in a form of outside group support (For Phase II, II and IV clients).
  • Continued eligibility will be reviewed monthly and determined by individual’s treatment progress.

Grant Application Process

  • Complete and submit application form with clinician
  • Sign release of information for clinical and/or criminal records
  • Executive Clinical Review and Approval
  • Notification of acceptance or rejection to client within 96 hours (business days).

What Is Covered

  • Initial Treatment Assessment
  • Initial Doctors Appointment
  • Medication
  • Phase I – IOP – 6 Weeks
  • Phase II – 6 Weeks
  • Phase III – 4 Weeks
  • Phase IV – 4 Weeks

We are excited to be able to treat persons who have no resources and hope that you commit to your recovery. We will do our best to “meet you where you are” and walk with you during your treatment but ultimately you must do the work to get and keep your recovery

ENSO Recovery Self Pay and Grant Application
Treatment Information

Instructions


Please complete entire form.
The fields with red asteriks are required.
When you select "Submit" a copy will be stored in the Cloud and you will receive a summary email and you will have an option to download the file in PDF format when you see the submission successful screen.
All Historical Referral Data is stored in the Cloud and can be downloaded into Excel or CSV format upon request for simplifying Grant Reporting.

dd/mm/yyyy
Please Verify Working Number
Enter Name of Individual
Secondary Drugs such as Cocaine, Marijuana, Meth, Benzos
Check all that apply
Amount Consumed per Occaision

Indicate which, if any, of the following have been present during the past 12 month period.

Count all check marks, and place client on the opioid disorder severity scale: Check one.

Add up your check marks and put a check next to one .


On a scale of zero to ten, with zero meaning you are not ready at all to make a change and ten meaning you are ready to make a change now,

Check Box if Yes

AGREEMENT EXECUTION INSTRUCTIONS


1. Please fill in Client's Printed Name
2. Please fill in Date form completed and signed
3, Submit Form
4. Download, Save and Pr
5. Both Client and Clinician need to sign document.

This form is the property of ENSO, LLC and may not be copied or reproduced without permission of ENSO, LLC.
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