Therapeutic Program Scholarship

Date of Application:

Applicant's Name

Your email

Applicant's Current Place of Treatment:

Address of Current Place of Treatment:

Amount of Funding Requested:

Case Manager's Name (If Applicable):

Case Manager's Contact Information (If Applicable):

How did you hear about us?

Who is your current health insurance provider?:

Please explain how receiving financial assistance from this foundation will assist you:

What is your inspiration to maintain long-term recovery?

What are your long-term personal goals?

I understand that funding is to help offset costs associated with treatment and are paid directly to the facility.

Signature of Applicant:

Signature of Case Manager:

Date:

"Don't Quit Five Minutes Before The Miracle Happens"