FUNDING APPLICATION

To be compelted by referring professional

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

Employed

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 info@leighshelp.org

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.