Grant Form

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:

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