FUNDING APPLICATION

Aftercare Coordinator | Therapist | Counselor Name

Email Address

Phone Number

Facility Name

Name Of Recovery House

Recovery House Address

Recovery House Address Line Two

Recovery House City

Recovery House State

Recovery House Zip

Contact Person

Contact Person Phone

Contact Person Email

Weekly Cost

Is accepting house aware intake fees/security deposits must be waived? Is accepting house aware intake fees/security deposits must be waived? Yes No

Please Explain Need For Assistance

Applicant Name

Applicant Phone

Applicant Email

Applicant Last Known Address

Applicant Last Known Address Line 2

Applicant Last Known City

Applicant Last Known Zip

Applicant Last Known County

Employed Employed Yes No

Have You applied to other organizations for financial assistance? If so please list below. Have You applied to other organizations for financial assistance? If so please list below. Yes No

Resource Name

Resource Contact Email

Resource Name

Resource Contact Email

Resource Name

Resource Email

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

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