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tlitadmin
2023-10-30T14:29:14-05:00
Apply for Assistance
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Name
*
First
Last
Email
*
Phone
*
Date of Birth
*
Gender
*
Male
Female
Age
*
Ethnicity
Marital Status:
*
Single
Married
Divorced
Widowed
How did you hear about our Program?
Are you receiving income benefits?
Yes
No
If Yes, Explain Benefits
Are you willing to work a full-time job?
Yes
No
Do you currently have a job?
Yes
No
Are you capable of working a full-time job?
Yes
No
If no, explain
Where?
Current Treatment Center
Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have a sponsor?
Yes
No
Name and Phone #
Phone
Name of Contact
Contact Phone
Completed Treatment?
Yes
No
Date
Estimated Date of Completion
Do you have pending or current cases in the court system?
Yes
No
If yes, explain
Currently Living
Streets
Shelter
Detox
Jail / Prison
Friend
Family
Transitional Treatment
Name of Sober Living House you are applying for
Website / URL
Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name of Contact
Contact Email
Contact Phone
What led you to Sobriety and how long have you been sober?
*
What are the goals for the Future? (short term-next 6 months)
What are the goals for the Future? (long term-next 1 to 5 years)
Are you a spiritual person?
Do you believe in a higher power?
Financial Statement
Income
Rent
Phone
Car Note
Insurance
Food
Credit Cards
Additional Debt / Expenses
Is anyone financially dependent on you?
Are you willing to check in and keep us updated on how you are doing?
• Thank you note for grant
• 2nd note about your 1st goal or milestone achieved ( 3 month )
• 3rd note about your 2nd milestone or goal reached ( 6 month)
• 4th note about someone you helped or a 3rd goal reached.
File Upload - Letter from You
*
Click or drag a file to this area to upload.
Tell us why you feel you deserve help and why have you chosen us? Your goals and plans for staying sober? What have you accomplished so far?
File Upload - Letter from Sober Living House
*
Click or drag a file to this area to upload.
Attach a recommendation letter from the sober living house you are applying to. This recommendation must include:
a. An explanation of the applicant's previous treatment history.
b. What makes this applicant a good candidate for your sober living house
File Upload - Letter from your sponsor
*
Click or drag a file to this area to upload.
File Upload - Copy of Completion Certificate
Click or drag a file to this area to upload.
Notes
If this is the first time this Sober Living House has used our scholarships from our Foundation, the vetting process of this application could take up to 2 weeks.
Submit
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