The Hope Shot Sober Living Funds Request Form

The Hope Shot Sober Living Funds Request Form

This form must be completed to the best of your ability, to be considered for funding.
What is your Name?*

First NameLast Name
Do you have an Email? (Not your case manager's)*

YesNo
Your Email?*
example@example.com
Your Date of Birth?*

MonthDayYear
Date
What Gender are you?*
what is your Race?*
What city and state are you in?*

Street Address Line 2

CityState

Postal / Zip Code
Are you on disability?
Which statement best describes the reason for funding requested:*

I'm in treatment/detox and need funding for new residenceI'm at sober living and need additional fundingI'm coming from jail/prison and need funding for new residenceOther
Have you previously been to a sober living facility?
Which sober living were you previously at?*
Which Treatment Center are you at right now?*
Other Name of Treatment Center not listed*
Which Jail/Prison are you coming from? *
Other Jail/Prison not listed? *
Discharge planners/Re-entry coordinator Phone Number*
Please enter a valid phone number.
Extension Number
Please enter the extension
What is your Discharge date?*

MonthDayYear
Date
What is the Reason you are requesting additional funding for sober living?*
Please specify the reason for this request that is not listed?*
What is Your phone number?*
Please enter a valid phone number.
Which Sober Living are you at or going to?*

Women at the WellRuth HouseBoaz HouseAce OpportunitiesHarmony HousePathways Recovery HomeThe Boat YardReal Recovery New Port RicheySteps To RecoveryARC PascoThe Rope CenterVictory HouseOxford House Peace RiverOxford House Land O LakesOxford House Gulf OasisOxford House Grace ValleyDa Vinci Recovery HomesARC PinellasReal Recovery BrandonReal Recovery BradentonReal Recovery ClearwaterReal Recovery North TampaReal Recovery St PetersburgOther
Other sober living house not listed?*
What is your drug of choice?*

OpiatesMethCocaineMarijuanaAlcoholBenzosOther
Other Drug of Choice not listed?*
Do you have a history of Overdoses*

YesNo
Do you have a disability/physical limitation that will prevent you from working?*

YesNo
Are you homeless?*

YesNo
Do you have health insurance?*

YesNo
Do you have EBT?*

YesNo
Do you have driver's license?*

YesNo
Do you have identification card?*

YesNo
Do you have birth certificate?*

YesNo
What city and state were you born?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have social security card?*

YesNo
Are you taking any medication(s)?*

YesNo
What medication(s) are you prescribed?*
Have you ever been tested for HIV or Hepatitis C?*

YesNo
Would you be interested in free testing?*

YesNo
Are you a veteran?*

YesNo
What branch did you serve?*
Time frame of active duty?*
Were you deployed in support of combat?*

YesNo
Do you need any of the following services*

Detox treatmentOutpatient treatmentInpatient treatmentMental health servicesOther
Other services requested not listed*
IF YOU RECEIVE FUNDING FROM THE HOPE SHOT, YOU WILL BE ASSIGNED A RECOVERY COACH AND WILL BE REQUIRED TO ENGAGE WITH YOUR COACH FOR A PERIOD UP TO 90 DAYS.*

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