(844) 927-9137

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

    Your Name (required)

    Email Address (required)

    Phone Number (required)

    Date of Birth

    Address

    City

    State

    Zip Code

    Applicant’s Parent/Guardian(s) Name

    Total Household *Income (including wages)

    Number of Household Members

    Do You Have Health Insurance?

    If Yes, Name of Insurance Company

    Do You Have Any Other Health Coverage?

    If Yes, Please Explain

    Have You Ever Been To Treatment Before?
    YesNo

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    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.