To be compelted by referring professional

Is accepting house aware intake fees/security deposits must be waived?


Have You applied to other organizations for financial assistance? If so please list below.

Do you have an specific aftercare plan? Please email a letter of commitment from client to

After Care Plan Submission

Certification that NO other financial assistance is being accepted from federal, state, county, friends, family or organizations other than the Leigh Leckerman Foundation.

13 + 12 =

*Please be advised NO funding will be granted without a completed and approved application.