NEW DAY ADVENTURES IN RECOVERY

FINANCIAL AID APPLICATION

 

Please answer all questions on this form. The more specific you are, the easier it will be for us to accurately evaluate your situation. Incomplete forms or incorrect information may cause delays in the application process.

1. Applicant Basic Info

Client first nameClient last name

Client phoneClient email

Client gender DOB: Client birthdate Marital Status: Client marital status

2. Family Member Support (if any)

     a. Name: Text field Relationship: Text field       Phone Number: Text field

     b. Name: Text field Relationship: Text field       Phone Number: Text field

     c. Name: Text field Relationship: Text field Phone Number: Text field

3. Explain your current financial situation: Include detais on income/cash assets.

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4. How much are you able to pay toward treatment or sober living on a monthly basis? Text field

5. Have you applied for or recieved any form of financial assistance or aid in the past 12 months? Dropdown

If you answered yes, please provide details, including amounts.

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6. Reason for Financial Assistance Request:

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7. Why do you believe you are a good candidate to recieve Financial Assistance from New Day Adventures In Recovery?

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8. Please tell us about yourself and your current life situation:

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By signing this form you are confirming the validity of the information provided. You are authorizing New Day Adventures in Recovery to make all inquiries deemed necessary to verify the accuracy of the statements made herein. You are aware that any misconduct on your behalf could result in the revoking of financial assistance and/or enrollment in treatment programs.

Signature: Signature Date: Date

 

FOR EMPLOYEE USE ONLY

Interviewed By: 

Suggested Treatment Center or Sober Living: 

Proposed Assistance Amount: 

Date Reffered to the Board: 

Baord Approved Assistance Amount: 

Board Decision: 

Notes: