Treatment Partner Scholarship Request
Detailed outline of Scholarship Request
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Email *
Scholarship Applicant Name *
Scholarship Applicant Contact Information *
Your Name and Organization  *

Please describe, in as much detail as possible, the details of the scholarship request.  

The information provided must include, but is not limited to, the following:

- All intake screening
- Clinical
- Financial
- Timeline of the Scholarship Request
- Proposed Treatment Plan for the scholarship recipient
- Proposed Length of Stay
- Proposed investment of the Foundation
- Potential After-Care planning and funding
 *
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