Financial Assistance Request

Through the generosity of donors, we have established a fund to be used strictly for families that have have a member that is dealing with substance abuse disorder and are experiencing financial hardship and need assistance for counseling services. All requests are confidential.

Name*

First NameLast Name

Email*

example@example.com

Cell Phone Number*

Area CodePhone Number

Please select:*

We are requesting financial assistance and need referral to a counselor.We are requesting financial assistance and currently are working with a counselor.

Upon submission, one of our representatives will reach out to you with 24-48 hours for more information.

Thank you.