Apply for a Treatment Scholarship

Recovery Foundation

Application for Treatment Scholarship

Please fill out the form below and someone will contact you with instructions on applying for a treatment scholarship.

*Individuals with Health Insurance (except Badger Care) or other financial resources are not eligible for Recovery Foundation Scholarships. Income verification will be required. *Once the scholarship application has been reviewed, a Connections counselor will be notifed of the status of your application and amount approved; the counselor will notify applicant with this information. *Scholarship recipients are responsible for a $10 copayment for each service received at Connections Counseling, i.e., each session of individual or group counseling. *Psychiatric (MD) services are not covered by Recovery Foundation Scholarships.

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

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?

Have you received Recovery Foundation Scholarship Funding before?

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 subtance 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; and describe your level of motivation for maintaining sobriety.

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