The Hope Shot Sober Living Funds Request Form
This form must be completed to the best of your ability, to be considered for funding.
Name
*
First Name
Last Name
Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
City and State
*
Street Address Line 2
City
State
Postal / Zip Code
Phone Number or Contact Person
*
Please enter a valid phone number.
How much funding are you requesting?
*
The funding you are requesting is for:
*
I'm in treatment/detox and need funding for new residence
I'm at sober living and need additional funding
Other
Which Treatment center
Reason for additional funding
Other Funding Reason
Name and city of sober living house
*
House managers phone number
*
Please enter a valid phone number.
Drug of choice:
*
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Other
Other Drug of Choice
Do you have a history of Overdoses
*
Yes
No
Do you need any of the following services
*
Detox treatment
Outpatient treatment
Inpatient treatment
Mental health services
IF YOU RECEIVE FUNDING FROM THE HOPE SHOT, YOU WILL BE ASSIGNED A RECOVERY COACH AND WILL BE REQUIRED TO ENGAGE WITH YOUR COACH.
*
By acknowledging the above statement, please print name for signature above.
JotForm
True
Submit
Submit
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