Recovery Form

Thanks for taking a huge step in your recovery. We are so glad you are here taking your first swing! You can do this!

Please know that filling out this application does not guarantee that you will receive funding.

Many factors go into making a decision to help someone, so when filling out your application, please make sure that all questions are answered.

They chance of getting help is higher if you’re in a rehab when you apply.

The section for your story should include what’s going on currently in your recovery and what your plans are going forward. This is a very important part of the process. For example, do not write a vague sentence that just says, ” I need money.”.

Recovery Form

    First name

    Last name

    Your email

    Home Phone

    Mobile Phone

    Family Contact Name

    Family Contact Number

    Birth Year

    The county listed on your ID

    The State listed on your ID

    Inhabitants (Choose most appropriate)

    Currently Living Now (select all that apply)

    Describe the situation where you are now (optional)

    Name of Recovery house (optional)

    Do you need funding? (optional)

    Check all that apply.

    Your story and why you need assistance.

    Have you called anyone else for assistance? If so, why or why not?