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Financial Assistance Pre-Questionaire
The questionnaire will take about 15 minutes. Sections 6 is to finish the application process.
This does not guarantee assistance; the form is a tool to help up determine if you may be eligible for financial assistance with part of your weekly fees. If approved you may be required to cover part or all of your fees until determination is made - this can take up to 60 days. *All Information is kept confidential
What is the reason you are seeking Therapeutic Sober Living? *
Your answer
Legal Name (as it appears on your Birth Certificate) First Middle Last *
Your answer
List any aliases or other names you have been known by. (e.g. nicknames, maiden name...)
Your answer
Current Street Address (If Homeless, note when you became homeless) *
Your answer
Current County of Residence *
Your answer
Phone Number *Voicemails/Text may be left at this number unless you note "contact me only" *
Your answer
Email Address *Emails may be left at this address unless you note "contact me only" *
Your answer
Gender *
Required
Are you pregnant? If so, how many weeks & what is due date. *Add OBGyn to referral source *
Your answer
Who gave your Independence Again's Information - Referral Source(es) *Include Person Name, Agency and Phone Number (all referral sources) *
Your answer
Marital Status *
Required
Ethnicity (Check all that apply) *
Required
Language *
What is your highest level of education? *
Are you interested in going back to school? *
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