Application for Assistance

Application for Assistance
Application for Assistance

Completing this application does not guarantee financial or material assistance. All applicants must meet UnforsakenMinistry’s qualifications and provide supporting documentation as requested to be considered.

Application and Drug Test Requirement
Before being considered for any financial or material assistance, applicants must complete an application in full and pass a drug test.

Graduate Assistance
Limited financial help may be provided to graduates who have successfully completed an Unforsaken Ministry recognized long-term faith-based rehab program without a positive drug test or major disciplinary issues.

Financial Evaluation Meeting
Applicants must meet with a representative of Unforsaken Ministry to review their current financial situation and discuss plans for future financial stability.
Name:
Date of Birth:
Gender
Driver's License/ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home):
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Cell):
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Briefly describe your need (rehab intake fees, medical, dental, emotional, housing, utilities, etc.) and explain how this financial assistance will help your recovery and stability:
Employment, Income, and Expenses Information
Current Employer:
Location:
Phone:
Position:
Length of Employment:
Monthly Income:
Other Income:
Total Monthly Income:
Total Monthly Expenses
Current Housing Information
Current Housing Situation:
Landlord/Property Manager Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Monthly Rental Amount:
Move-In Date (if applicable)

MonthDayYear
Date
Program Information
Are you a graduate of a rehab program?
Name of Rehab Program:
Graduation Date:

MonthDayYear
Date
Have you had a positive drug test or disciplinary issues since graduation?
Date of Last Drug Test:

MonthDayYear
Date
Result of Last Drug Test:
How many times have you been in rehab?
Number of years in addiction:
List drug(s) of choice:
Complete the appropriate section(s) below:

Rehab Intake Fee Assistance
Name of current/requested rehab facility:
Contact Name:
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Total Cost of Intake Fee:
Amount Being Requested:
Date Assistance is Needed:

MonthDayYear
Date
Medical Assistance
Name of Doctor/Hospital/Facility:
Contact Name:
Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Total Estimated Cost:
Amount Being Requested:
Do you currently have Medical Insurance?
If so, who is your Insurance Provider?
Date Assistance is Needed:

MonthDayYear
Date
Dental Assistance
Name of Dentist/Facility:
Contact Name:
Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Total Estimated Cost:
Amount Being Requested:
Do you currently have Dental Insurance?
If so, who is your Dental Insurance Provider?
Date Assistance is Needed:

MonthDayYear
Date
Mental Health Assistance
Name of Doctor/Hospital/Facility:
Contact Name:
Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Total Estimated Cost:
Amount Beint Requested:
Do you currently have Medical Insurance?
If so, who is your Medical Insurance Provider?
Date Assistance is Needed:

MonthDayYear
Date
Housing Assistance
Number of current household members:
Number of children living with you:
Ages of children:
Requested Housing Assistance

Answer all that apply.
Utility Deposit(s) - Amount Being Requested:
Utility Bill(s) - Amount Being Requested:
Rent - Amount Being Requested
Household Goods - Amount Being Requested
List Household Goods Needed
Other - Amount Being Requested
Please specify other needed goods:
Date Assistance is Needed:

MonthDayYear
Date
Other Assistance
Specify any other needs in detail.
Amount Requested for Other Assistance:
Date Assistance is Needed:

MonthDayYear
Date
Financial Evaluation
Are you willing to meet with an Unforsaken Ministry representative to discuss your financial situation and plans for future financial health?
Briefly explain how this financial help will assist your recovery and stability:
Authorization & Agreement
I certify that the information provided above is true and complete to the best of my knowledge. I understand that any false or misleading information may result in denial of assistance. I agree to take a drug test if requested and to meet with a representative of Unforsaken Ministry to evaluate my financial situation.
Signature
Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

Application for Assistance

Employment, Income, and Expenses Information

Current Housing Information

Program Information

Complete the appropriate section(s) below:

Medical Assistance

Dental Assistance

Mental Health Assistance

Housing Assistance

Requested Housing Assistance

Financial Evaluation

Authorization & Agreement