Apply for a Treatment Scholarship Women

First Name *

Last Name *

Phone *

Address *

Address 2

City *

US States *

Zip

Please specify your ethnicity? *

White
Hispanic or Latino
Black or African American
Native America or American Indian
Asian of Pacific Islander
Other
I prefer not to answer

Have you received financial aid from The Family Restored before? *

Age *

18-24
25-34
35-44
45-54
55-64
65+

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What is your current drug(s) of choice? *

Do you have any issues aside from drugs and alcohol that need to be addressed? *

If you answered yes to the above question, please explain:

Have you tried treatment before? *

If you answered yes to the above question, describe the conditions under which you left the previous program(s) and your follow through upon leaving:

Do you have any legal problems that may prevent you from being out of state for up to 6 months? *

If you answered yes to the above question, please explain:

All of our Treatment Partners are abstinence based and have restrictions around medications. What medications are you currently taking? *

What is your current living situation? *

In your own home/apartment
With parents/family
Couch surfing
Shelter
Detox/Treatment
Other

If you are in a detox, holding or alternate facility, please leave your Case Manager's contact info here. *

Will you allow family to be a part of your treatment plan? *

If yes, please list contact information for family

How did you hear about The Family Restored *

Word of mouth
Friend/Family
Internet search engine
Social Media
Recommendation from detox or treatment center
Other

If you are a Massachusetts resident, are you willing to section yourself and spend a few weeks in a holding before getting a scholarship? *

If you are living in Massachusetts, do you currently reside in Essex, Middlesex or Suffolk county? *

Do you have Health Insurance and have you attempted to enter treatment with your insurance? *

Do you currently receive SSI, SSDI, food stamps, Section 8 or any other form of state insurance? *

If you answered yes to the above question, please explain how much you receive: *

If a partial scholarship is available, how much can of your financial means including support from family, friends and local church can you contribute? *

In a short paragraph please tell us why you should receive the Family Restored scholarship. Please include any details about your financial needs. *

STATEMENT OF UNDERSTANDING: The Family Restored (TFR) Scholarship is for individuals willing to commit to a 12-Step abstinence based program for a minimum of 6 months and in need of financial assistance. Scholarships are granted on a monthly basis and only awarded to individuals willing to follow the suggestions of The Family Restored representative working with them. You must be willing to relocate for six months or longer and communicate with a TFR representative weekly to discuss how your recovery is progressing. TFR will review your application and complete a screening, if you are eligible for a scholarship it can take 2 weeks to place you in a program of TFR's choice. You will need to display willingness and follow through in that time in order to continue to be considered for a scholarship. *

I understand this commitment and agree to these terms

Apply for a Treatment Scholarship – Women