Operation Rise Again Submission Request

Applicants must be willing to commit to 90 days or more of treatment. Those applying must be ready to move forward with treatment immediately upon approval. Applicants must be willing to go to any length for victory over their addiction. Approved scholarships may be revoked in the event that applicants begin to show a lack of willingness and/or are unable to conduct themselves respectfully throughout the intake process.

 Name:

Client first name         Client last name

Client nickname

Contact:

Client phone        Client email       

 

 

Are you requesting assistance for yourself or a loved one? Text field

How did you hear about "ORA"? Text field

Please type a brief description on how we can help: Paragraph

 

 
Please complete this form honestly. All answers are confidential and used solely to determine your eligibility for scholarship assistance.

1. Treatment History
Have you ever been to treatment before? 

Checkboxes 

If yes, where and how long ago were you in treatment? Text field

Are you currently in any outpatient programs? 

Checkboxes
Are you currently attending any AA, NA, CA, or church meetings?

Checkboxes
If yes, do you have a sponsor? 

Checkboxes


2. Current Use & Medical Needs
Are you presently using any narcotics or drinking?
Checkboxes
Will you need to detox prior to treatment?
Checkboxes
Are you on disability?

Checkboxes

Do you currently take any medications?

Checkboxes

 If yes, what kind? Text field

3. Personal & Family Information
Are you married?
Checkboxes
Do you have any children?
Checkboxes
If yes, do they live with you?

Checkboxes
What is your current living situation?

Text field

4. Employment & Financial Details
Are you currently employed?
Checkboxes
If yes, does your place of employment offer any financial assistance?

Checkboxes

Are you able to contribute financially toward the scholarship?

Checkboxes

If not now, would you be willing to contribute after treatment when able?

Checkboxes

Do you have a form of identification?

Checkboxes

5. Commitment & Logistics
If accepted, are you willing to leave for treatment today?
Checkboxes
Would you need transportation to the facility?
Checkboxes
Are you willing and able to commit to 90+ days of treatment?
Checkboxes
Are you willing to go to any lengths for victory over your addiction?
Checkboxes

6. Military Affiliation

Are you a veteran? Client veteran status

Have you ever served in the military? 

7. Legal Status
Are you a registered sex offender

Checkboxes