Apply for a Treatment Scholarship

Recovery Foundation

Application for Treatment Scholarship

Please fill out the form below and someone will contact you with more information.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Gender, Date of Birth, Ethnicity

Have you received Recovery Foundation Scholarship Funding before?

Are you seeking assistance with….

Please describe the type of assistance you are seeking from Recovery Foundation.

Do you currently have health insurance that covers mental health and/or substance abuse related treatment? If so, please describe why the insurance is unable to cover the scope of your treatment?

Are you currently engaged in professional inpatient or outpatient treatment?

Name of treatment facility and primary counselor or contact:

May we contact above for supporting information?

Are you currently in recovery housing?

What recovery housing facility is your home and when did you move in?

Do you have a committment from a recovery housing facility? If yes, what facility and your planned move-in date?

Are you employed? If so, what is your weekly income?

Please explain why, financially, you believe you should be considered for a Recovery Foundation scholarship? Explain any special circumstances (medical bills, illness, etc); also explain other forms of assistance. (ie: disability, parental support, other people who provide financial support to you for living expenses)

Are you currently in recovery for substance abuse? If so, how long has your current sobriety been? (# days sober)

Are there any additional circumstances that you would like to be taken into consideration? If so, explain.

Explain why you should be considered for this scholarship. What steps are you taking to strengthen and maintain your recovery?

If you completed this form for someone else using your contact phone or email, how can we reach the applicant directly in the future (phone or email…)?

Please list as much contact information as possible even if it is not accessible at this moment (for example phone may not be accessible now if individual is in residential treatment).