Do you have health insurance?
Children (list names, ages, custody, and living arrangements for each child):
Mother's name and contact number:
Father's name and contact number:
Current and previous physician’s names and contact numbers:
Any previous therapist/counselor(s) name and contact number(s):
Current counselor’s name, email, and contact number:
Where were you living before treatment, or if not in treatment, where are you currently living:
If you are in treatment, what is the name of the facility, type of treatment (such as residential, IOP, etc.), and how long you have been in treatment:
What is your expected date of discharge: ?
If you are currently in treatment and have an anticipated discharge date, please specify if the
discharge is due to successful graduation/completion of program or failure to comply with
program or inability to pay for additional treatment with current program.
How was your current treatment paid for:
Have you had any previous treatment for addiction? If yes, please include name of facility, date of participation, how long the treatment was, and if it was successfully completed:
List any other medical or psychological conditions for which you are currently being treated or have been treated in the past and include names of medical and clinical providers and any medications you are currently prescribed or have been prescribed:
List any names of medical and clinical providers and any medications you are currently prescribed or have been prescribed in the past.
Do you currently have any outstanding legal issues? Please include any outstanding warrants and any past/current/pending charges, upcoming court dates, etc.:
Are you currently employed? If not, how are you currently being provided for?
What job opportunities will you pursue during your stay in sober living and do you have any leads or prospects already?
What kind of work experience do you have and in what field?
Do you have a degree or other vocational training, if so, what kind and in what area?
If you don’t have a college degree or vocational training, do you plan to pursue more school, and if so in what area?
What can you offer as your financial contribution to your stay in sober living if a Scholarship if is awarded to you?
What is your history with substance abuse?
Why should we consider you for a scholarship? Please feel free to advocate for yourself.
If you are not eligible for a scholarship, what are your alternative plans:
Are there any foreseeable complications or issues that may prevent you from completing the treatment recommendations if you are awarded a Scholarship? ?
Be as honest and thoughtful as possible in the section above. (Please note that any possible
complications disclosed here will not necessarily disqualify you as a Scholarship candidate, but will help
us customize your treatment program)
Do you have any special circumstances that we should consider?