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2. First Name*
3. Last Name*
5. Gender*

   1. Male
   2. Female
   3. Other
6. Date of Birth*
   Date of Birth
7. Marital Status*
9. Phone Number*
11. Email Address*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Are you or could you be pregnant?*

    This will not affect your application it will only help with placement. Please check the appropriate response below

    1. Yes
    2. No
21. Do you have children? If so, how many?
23. How did you hear about our program?
25. Have you previously applied for our Scholarship within the past three months?*

    1. Yes
    2. No
27. What is your current living situation (in your own home/apt, with parents/family, couch surfing, shelter, etc.)?
29. Do you have a support system? If yes, please explain.
31. If you are in a detox, holding or alternate facility, please give your Case Manager's contact information below:
33. What is your current substance(s) of choice?
35. Have you tried treatment before?
37. Do you have any challenges aside from drugs and alcohol that need to be addressed (i.e. eating/exercise disorder, self-harm, abusive relationship, mental health etc.)? If yes, please explain.
39. Are you willing to discuss any medical conditions you may have that we or the sober house should be aware of?*

    1. Yes
    2. No
    3. N/A
41. Are you willing to discuss any medications you are currently taking?*

    1. Yes
    2. No
    3. N/A
43. Are you willing to relocate for a minimum of 30 days?*

    1. Yes
    2. No
45. Please explain your need for financial assistance below:
47. If a partial scholarship is available how much can you contribute to your sober living costs?
49. What have you done to try and secure finances to enter a sober living or recovery home before applying for a scholarship?
51. Do you understand this application is not for a specific rehab or program? We will review your application and if eligible will place you in a facility of our choice. If you understand and still want to apply select YES below:*

    1. Yes
    2. No
53. If you are eligible for a scholarship it will take a minimum of 48 hours for us to review your application and respond. Please confirm you understand this and select YES below:*

    1. Yes
    2. No
55. Are you willing to meet with a Recovery Coach to discuss how your recovery is progressing and establish your continued need for a scholarship?*

    1. Yes
    2. No
57. Are you willing to go to detox and 30 days of treatment before entering a recovery house?*

    1. Yes
    2. No
59. Do you have any pending legal problems? If yes, please explain.
61. Please provide your Emergency Contact information below:
63. Are you willing to provide your health insurance information during a potential follow up interview? If you do not have any coverage select N/A below*

    1. Yes
    2. No
    3. N/A
65. Do you currently receive SSI, SSDI, food stamps, Section 8, or any other form of state assistance?
67. Is there any reason you cannot be employed?
69. Are you open to being required to go to meetings?*

    1. Yes
    2. No
71. In a few sentences please tell us why you should receive this scholarship:*
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field