FUNDING APPLICATION

To be compelted by referring professional

(Please submit application no less than 72 hours prior to discharge. A submitted application is not an approval. Any clients being sent to housing without written approval will be denied)

Aftercare Coordinator | Therapist | Counselor Name

Email Address

Phone Number

Facility Name

Approximate Discharge Date

Will applicant be relocating to a new county or state? Will applicant be relocating to a new county or state? Yes No

Applicants Insurance Info

Have you applied to other organizations including county or state resources for financial assistance? Have you applied to other organizations including county or state resources for financial assistance? Yes No

Recovery House Address

Recovery House Address Line Two

Name Of Recovery House

Recovery House State

Recovery House Zip

Contact Person Phone

Recovery House City

Contact Person

Contact Person Email

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

Do you have an specific aftercare plan? Please email a letter of commitment from client to info@leighshelp.org Do you have an specific aftercare plan? Please email a letter of commitment from client to info@leighshelp.org Yes No

Signature

After Care Plan Submission After Care Plan Submission In addition to the application please submit letter of commitment to complete aftercare plan from the scholarship recipient in order to consider for approval to info@leighshelp.org This will be shared with housing if approved and client must complete aftercare to be funded.

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

Facility for IOP, OP, PHP or other and contact information for aftercare provider.

4 + 12 =

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

The Leigh Leckerman Foundation is an emergency source of funding when ALL other resources have been denied or exhausted.