Sober Living Assistance Program - Teach One Feed One

Sober Living Assistance Program Application

Teach One Feed One’s Sober Living Assistance Program provides funding, meals, clothing, furniture, personal hygiene products and other in-kind means to individuals entering treatment, in addition to those that have successfully completed treatment as well.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Age(Required)

Sex(Required)

Race(Required)

Phone(Required)

Email(Required)

Today's Date(Required)

Sober/Recovery Home you will be going to:(Required)

Sober/Recovery Home Contact Name:(Required)

Sober/Recovery Home Contact Number:(Required)

Sober/Recovery Home Contact Email:(Required)

How did you hear about us?(Required)

Have you ever applied for assistance from Teach One Feed One before?(Required)

Yes or No? If yes, explain.

Do you have any friends, relatives, or acquaintances that work for Teach One Feed One?(Required)

Yes or No? If yes, state name & relationship

Are you 18 years of age or older?(Required)

Yes

Do you have a drivers license?(Required)

Yes

If yes, is it currently active or suspended?(Required)

Yes

Do you have a car?(Required)

If not, tell us briefly how you plan to travel to and from work?

If accepted, will you consent to a mandatory controlled substance test at any point during the duration of this Scholarship?(Required)

Yes

How long do you have clean/sober?(Required)

Are you open to a 12 step program?(Required)

What is your DOC? (Drug of Choice)(Required)

What is the longest stint of clean time you’ve had?(Required)

Do you have family support?(Required)

If yes (emotionally /financially/both)

Is this your first time in treatment?(Required)

If not (How many?)

In your HONEST opinion, whats stopping you from staying clean? And how will this assistance help you achieve long term sobriety?(Required)

Signature(Required)