Sponsorship Application

DRIVEN Neuro offers services on a sliding scale based on the Federal Poverty Level. We are committed to ensuring that financial hardship does not limit access to recovery and wellness services. This application collects household details and income information to determine eligibility for sponsorship. Documents will be visually verified by DRIVEN Neuro staff and will be returned to client/member. Any documents left with DRIVEN Neuro will be securely disposed following review.

Please note: Sponsorships are only applicable to services specifically recommended by the Director of Neuro Services in the DRIVEN Neuro Program Agreement following completion of the initial evaluation. If you choose to add services or increase the frequency of services beyond these recommendations, any such additional services will charged the standard a la carte rate and will not be eligible for sponsorship or other discounts.

How many people live in your household (including children under the age of 18)?

Please list all household members, including yourself, below. For each member age 18 or older, indicate all sources of income and the monthly amount for each. Examples of income types include SSI, SSDI, Veterans Benefits, Child Support, Payroll, Unemployment, Retirement, Pension, Alimony, etc.

Rows	Full Name	Age	Relationship to Client	Source of Income	Monthly Income Amount
Client
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10

Required Proof of Income Documentation

Please submit proof of income for all household members 18 and older (in-person to DRIVEN Neuro's Client Care Coordinator or via email to DNLVClientCare@DRIVENNeuro.org). Acceptable documents include:

W-2 Employees: Provide copies of your two most recent paystubs.
SSI or SSDI Recipients: Submit your official, current award letter.
Other Income Types: For unemployment, retirement/pension, veteran benefits, child support, alimony, or other sources, please provide official statements, benefit letters, or other documentation verifying the monthly amount received.

Annual Evaluation for Continued Support

At the end of each sponsorship year, DRIVEN Neuro will review your scheduled services and sponsorship. This process helps ensure that support is tailored to your needs and that resources are allocated equitably. It is designed to be fair and objective, considering several important factors:

Progress: Your achievements and improvements within the program.
Trainer Feedback: Insights from trainers regarding your engagement, participation, and commitment.
Attendance: Consistency in attending scheduled sessions.
Payment Record: Timeliness and completeness of payments, when applicable.

Reasons for Sponsorship Adjustment or Termination

Sponsorships may be adjusted or discontinued for the following reasons:

Frequent late cancellations, as outlined in the Client/Membership Agreement.
Violation of Client/Membership Agreement terms.
Unpaid balances for two or more months.
Submission of false documentation.
Lack of participation in DRIVEN Neuro events, or lack of sharing stories for DRIVEN Neuro’s marketing and social media channels, when requested.

Reporting Household or Income Changes

If you are receiving financial support through sponsorship and there is a change in the number of members in your household or any household member aged 18+ experiences an income change, you must notify us as soon as possible, but no later than 30 days. You may also be required to submit a new sponsorship application and provide updated income documentation.

Questions?

If you have questions about which income documents are acceptable, the overall sponsorship process, or any of the eligibility criteria, please reach out to the DRIVEN Neuro Client Care Coordinator. We are committed to supporting your journey and maintaining a positive, equitable community for all clients and members. The Client Care Coordinator is available in person, by phone at (702) 463-4874, or by email at DNLVClientCare@DRIVENNeuro.org to provide guidance and answer any questions you may have.

Certification and Signatures

I certify that the above information is true and complete to the best of my knowledge. I will notify DRIVEN Neuro of any changes within 30 days.

DRIVEN Neuro Client Name

First NameLast Name

Designated Signer Name (if applicable)

First NameLast Name

Parent/Guardian Name (for minors under the age of 18) (if applicable)

First NameLast Name

Client, Parent/Guardian, or Designated Signer's Signature

Date Signed

Date

Sponsorship Application

Household Information