APPLICATION FOR FINANCIAL SCHOLARSHIP
THESOBRIETYRESOURCE.ORG | 770.322.4428 | info@thesobrietyresource.org
To begin the process of qualifying for scholarship consideration, you must submit a completed application, which includes all required supporting documentation. See the "Eligibility and Required Documentation Checklist" for details.
ELIGIBILITY AND REQUIRED DOCUMENTATION
CHECK LIST OF REQUIRED SCHOLARSHIP APPLICATION DOCUMENTS:
General Documentation:
Completed Financial Scholarship Application (NOTE: The online application follows this checklist and will not submit until all required fields are populated)
Copies of Identification (State issued ID, DL, Jail ID, SS Card, Birth Certificate, Passport) (Must Be Submitted to The Sobriety Resource Staff)
Declaration of Financial Need (Signed and Dated within Online Application)
Letter of Acceptance from Recovery / Treatment Provider (Must Be Submitted to The Sobriety Resource Staff)
Verification of Homelessness (if applicable) / Proof of Current Living Situation (Signed and Dated within Online Application)
General Release of Liability Form (Signed and Dated within Online Application)
Authorization to Release Personal Information Form (Signed and Dated within Online Application)
Proof of Income / Verification of Financial Need Please provide all applicable documentation that can be used to provide an accurate snapshot of your current financial situation. Helpful resources for securing the below include: irs.gov and dol.georgia.gov (Copies of Applicable Items Must Be Submitted to The Sobriety Resource Staff)
Last 2 Pay Stubs (if applicable)
Previous Year’s IRS Form 1040 (if applicable)
Income/Wages Report
Evidence of Department of Labor Unemployment Filing (if applicable)
Evidence of Child Support Payment (if applicable)
Evidence of Child Support Receipt (if applicable)
Evidence of any other Income/Expenses (as described on financial worksheet)
Insurance Coverage Information (if applicable) Please provide The Sobriety Resource staff with copies of current insurance card containing provider’s name, insurance type and effective date(s) of coverage plan. You will also be asked to provide details of your insurance coverage within the online application.
IMPORTANT:
* The Sobriety Resource does not hold scholarship openings. Available scholarship funds are limited due to funding and prioritized to those most in need.
* Uninsured applicants receive first priority for financial assistance.
* Incomplete applications will be returned to you (along with a list of missing information) and will not be processed until all required documents are received.
* All completed scholarship applications will be reviewed in the order they are received.
Prior to final scholarship approval, qualified applicants are required to attend a 15 minute virtual meeting with a member of The Sobriety Resource team. No financial assistance will be provided until this step has been completed.
NOTE: Please ensure you can provide the required documentation prior to completing this online application. Thank you.
PERSONAL INFORMATION:
FIRST NAME: Client first name
MIDDLE NAME: Client middle name
LAST NAME: Client last name
SOCIAL SECURITY #: SSN
GENDER: Client gender
DATE OF BIRTH: Client birthdate
RACE: Client race
LAST ADDRESS: Client Address
CITY: Client City ST: Client State ZIP: Client Zip
BEST PHONE #: Client phone
BEST EMAIL: Client email
MARITAL STATUS: Client marital status
REFFERED TO US BY: Client Referred By
Are you a Veteran? Client veteran status
Do you have health insurance? Radio buttons
If Yes, please complete: Insurances
NOTE: Please provide a copy of your insurance card with your completed scholarship application.
FAMILY BACKGROUND:
Family Members
CURRENT LIVING SITUATION:
Are you currently homeless? (See "Appendix A: Examples of Homeless Status" for official definitions of homelessness)
Radio buttons
IF APPLICABLE: How many times have you been homeless in the past three (3) years? Text field
Where have you been living for the past 30 days?
Checkboxes
IF "Other" Please enter here: Text field
SUBSTANCE ABUSE HISTORY:
Which of the following substances have you used at any time in the past? Please check all that apply.
Checkboxes
IF "Other" Please enter here: Text field
How old were you when you first used alcohol or controlled substances? Text field
What is your preferred substance(s)? Client substances of choice
Which substance(s) have you used most recently? Text field
TREATMENT/RECOVERY HISTORY
Tell us about your previous treatment/recovery experiences:
TreatmentCenterHistory
SoberLivingHistory
RecoveryHistory
Have you participated in AA or other self-help meetings?
Radio buttons
Kinds of meetings you have attended?
Client kinds of meetings attended
CRIMINAL HISTORY
Criminal History
Probation
Please share any pertinent details of your criminal history/background that might prove to be barriers to your recovery.
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EMPLOYMENT/EDUCATION INFORMATION
Are you currently employed? Radio buttons
EmploymentHistory
EducationHistory
INCOME EXPENSES WORKSHEET
*If you are unemployed, have your parents complete this section or explain how you have been supporting yourself in the “other expenses” area.
MONTHLY INCOME
| Your Gross Monthly Income |
$ Text field |
| Your Spouse’s Gross Monthly Income (If applicable) |
$ Text field |
| Child Support Received (If applicable) |
$ Text field |
| State or Federal Assistance (If applicable) |
$ Text field |
| Food Stamps Assistance (If applicable) |
$ Text field |
MONTHLY EXPENSES
| Rent / Mortgage Payment |
$Text field |
| Automobile Loan |
$Text field |
| Utilities (Electricity/Water/Gas/Etc.) |
$Text field |
| Phone |
$Text field |
| Child Care |
$Text field |
| Child Support |
$Text field |
| School Tuition / Loan |
$Text field |
| Other: Please ExplainText field |
$Text field |
How often are you paid?
Radio buttons
Do you share expenses with anyone living in your household?
Radio buttons
Total number of people living in your house? Text field
I have read and understand that in order to process my application, I must submit at least one of the following:
1. If you are working or retired with benefits: Prior year’s tax form 1040 (first 2 pages)
2. If you are unemployed: Proof of unemployment benefits
3. If you are disabled: Proof of disability benefits
4. If you receive SSI or SSA benefits: Proof of Social Security benefits
INITIAL HERE Initials Text field TO ACKNOWLEDGE YOUR AGREEMENT WITH THE REQUIRED DOCUMENT SUBMISSIONS.
SCHOLARSHIP STATEMENT
To help us better understand your situation, and ensure we provide the best possible recovery options, please answer the questions below. This information is confidential and will be used solely to process your scholarship application.
1. Have you received funding from The Sobriety Resource previously?
Radio buttons
2. How did you hear about The Sobriety Resource? (i.e., Website, google search, friend/relative (include name), program/agency (include name), other (please specify)
Text field
3. Which program / services have you applied for and why?
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4. What do you hope to gain through your participation in this program or through these services? (What are your goals/expectations? How will you measure your progress?)
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5. List 3 areas that you will work on during your participation in the recovery process.
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6. Give us a brief description of what has happened in your past to bring you to this point in your life. Please be as detailed as possible.
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7. How will this assistance help you in your recovery? How will this assistance impact your futures hopes and plans?
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SCHOLARSHIP AGREEMENT
I hereby certify that the above information is true and complete. I agree to inform The Sobriety Resource immediately of any changes to the above information. I understand that false information will jeopardize my scholarship assistance.
I hereby give permission to The Sobriety Resource and its representatives to contact individuals or employers for salary and bill verification, as well as to conduct a credit and/or criminal background check.
In order to maximize what The Sobriety Resource is able to offer, I understand that I will be asked to pay a percentage of my program fees.
SIGNED: Signature DATED: Date
NOTE: Your signature here certifies that you have read, understand, and agree with the above information as submitted by you to The Sobriety Resource.
DECLARATION OF FINANCIAL NEED
CERTIFICATION FROM APPLICANT:
I certify that I am currently in need of professional substance use disorder treatment and/or recovery services, and that I currently do not have the financial means to secure these services for the following reasons: [Please include information about your current living situation and employment status, as well as any family or support agencies who can provide verification of your current situation]
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I understand that I am required to provide documentation that supports my request for financial services, and I give The Sobriety Resource permission to verify any third-party information I provide (if needed).
SIGNED: Signature DATED: Date
NOTE: Your signature here certifies that you have read, understand, and agree with the above information as submitted by you to The Sobriety Resource.
VERIFICATION OF HOMELESSNESS
CERTIFICATION FROM APPLICANT:
I certify that I AM CURRENTLY HOMELESS and DO NOT have the financial means to secure housing for the following reason(s):
[Please be as detailed as possible and include backup documentation from support agencies or community resource providers who can verify your homeless status]
Text field
SIGNED: Signature DATED: Date
NOTE: Your signature here certifies that you have read, understand, and agree with the above information as submitted by you to The Sobriety Resource.
GENERAL RELEASE OF LIABILITY
I, Initials Text field, of CITY Text field of COUNTY Text field in the State of GEORGIA (Hereinafter the “Releasor”) for and in consideration of: (Check One)
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If "OTHER", Enter Description Here: Text field
THEREFORE under the terms of this Agreement and sufficiency of which is hereby acknowledged, do hereby release and forever discharge The Sobriety Resource, of Marietta, City of Cobb, State of GEORGIA (Hereinafter the “Releasee”) including their agents, employees, successors and assigns, and their respective heirs, personal representatives, affiliates, successors and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to the following:
Any service provided by The Sobriety Resource or its agents.
It is understood and agreed that this Agreement is made and received in full and complete settlement and satisfaction the causes of action, claims and demands mentioned herein; that this Release contains the entire Agreement between the parties; and that the terms of this Agreement are contractual and not merely a recital. Furthermore, this Release shall be binding upon the undersigned, and his respective heirs, executors, administrators, personal representatives, successors, and assigns. This Release shall be subject to and governed by the laws of the State of GEORGIA,
This Release has been read and fully understood by the undersigned and has been explained to me.
EXECUTED THIS DAY - Date
RELEASOR’S SIGNATURE: Signature DATED: Date
NOTE: Your signature here certifies that you have read, understand, and agree with the above information as submitted by you to The Sobriety Resource.
AUTHORIZATION TO RELEASE PERSONAL INFORMATION
| RESIDENT’S NAME: |
Text field |
DOB: |
Date |
| PROGRAM NAME: |
Text field |
SSN: |
Text field |
I request and authorize Text field to release and receive personal healthcare information of the resident named above to: The Sobriety Resource (Roswell, GA)
This request and authorization apply to:
Checkboxes
If "Personal Information" enter details here: Text field
Checkboxes
If "Other" enter details here: Text field
DEFINITION:
(1) This record which has been disclosed to you is protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this record unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed in this record or, is otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder except as provided at §§ 2.12(c)(5) and 2.65; or
(2) 42 CFR part 2 prohibits unauthorized disclosure of these records.
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. (THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED)
Radio buttons
SIGNED: Signature DATED: Date
TYPE FULL NAME HERE: Text field
WITNESSED BY: Signature
TYPE FULL WITNESS NAME HERE: Text field
NOTE: Your signature(s) here certifies that you have read, understand, and agree with the above information as submitted by you to The Sobriety Resource.
CONCLUSION:
Thank you for completing this online application form. You may hit the button below to submit your application to our intake team. Please be sure you have provided or are able to provide all of the required supporting documentations.
We look forward to supporting you in your recovery journey!
The Sobriety Resource Team
thesobrietyresource.org