Apply for a Scholarship to Assist with Detox or Rehab

The cost of treatment might seem out of reach.  Even with health insurance, there are still unforeseen expenses such as co-pays and travel.  Simply call the number or complete the form below and a Foundation Liaison will assist you with the scholarship process.

1-844-927-9137

Scholarship Application Form

Name *

First

Last

Scholarship Recipient Choose OneSelfImmediate Family MemberFriendOther

Phone Number *

Email *

Date of Birth

Address

Total Household Income

Number of Household Members

Do You Have Health Insurance?OptionsYes, Private InsuranceYes, Medi-CalNo

If Yes, Name of Insurance Company

Have You Ever Been To Treatment Before? *Yes/NoYesNo

Submit

Please note that this is an application only.  A Foundation Liaison will work with you to help process the application and present it to the deciding Board.