Assistance Application

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Funds Requested

Specify the dollar amount needed

Description of Need

Please use the space below to explain why this support is needed and how funds will be used.

References

For requests that exceed $50, we require two references, which can be family members, sponsors, friends, healthcare providers, etc. Please provide names and phone numbers and/or emails for both references. We will contacted them to verify you are working toward sobriety.

We are honored to be a part of your recovery process and stand by you during this time. Rest assured, we review ALL requests carefully and will reach out to you as soon as possible. While immediate approval cannot be guaranteed, please know that your request will be thoroughly considered. Thank you for trusting us.