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Name
Email
Phone
Address
Date of Birth
Employment Status
Annual Income
Proof
Why are you seeking treatment (substance abuse, eating disorder, mental illness)?
If substance abuse, will detox be needed?
Have you been treated before for this illness? If YES, please explain:
Please state services requested and approximate cost:
Do you have medical insurance?
If yes, please provide policy and group ID number:
Can you provide a recommendation from a primary care physician or therapist?
Is there any other information that you wish to provide?
Date:
Applicant Signature:
Menu
Skip to content
Home
About
Our Mission
Partnering Organizations
Blog
Events
Contact
Apply for Grant
Donate
Testimonials