Fill out this application for recovery housing and someone from our team will be in touch with you soon. Application Completed By(Required) Applicant (self) Case Manager/Discharge Planner Family Member or Friend Please Check OneDisclaimer(Required) I have read and understand what the scholarship covers and how it works.Important Information About Recovery Housing Scholarships Please review the following before completing your application: • Scholarships are intended only to assist with entry fees for individuals transitioning from a higher level of care (such as residential treatment, inpatient, or detox). • Scholarships may cover up to one month of housing or entry-related costs (in two-week increments). • Scholarships cannot be used for ongoing rent, deposits, or past-due balances. • Processing time for scholarship applications is typically 1–2 weeks. • Scholarship availability varies depending on the amount of funding we have at the time of your application.APPLICANT INFORMATIONName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If Not the Applicant, Please Provide the Following InformationName First Last Relationship to Applicant/TitlePhoneEmail RECOVERY RESIDENCE INFORMATIONPlease provide details about the recovery home where you plan to reside or are currently residing. This information helps us verify program eligibility and ensure scholarship funds are directed appropriately.Disclaimer(Required) I have read and fully understand what the scholarship covers.Covers up to one month of rent in a recovery home certified by a NARR affiliate or certified/licensed by another state recognized certifying bodyName of Organization(Required)Location (City, State)(Required)Is this program certified by a NARR Affiliate or another State Certification Body?(Required) Yes No If yes, please list the certifying bodyAmount Requested(Required)Contact Person or Program Staff(Required)Contact Phone Number(Required)Contact Email Address(Required) Additional Notes (optional)TREATMENT INFORMATIONAre you currently in a treatment center?(Required) Yes No If Yes, Please Fill Out the Following InformationName of Treatment CenterLocation (City/State)Date of Entry MM slash DD slash YYYY Estimated Completion Date MM slash DD slash YYYY Case Manager or Discharge Planner Name First Last Case Manager/Discharge Planner Contact InfoLast Date of Use MM slash DD slash YYYY Primary Drug of ChoiceSubstances Used in the Last 60 DaysHOUSING & RECOVERY HISTORYWhere Did You Live Prior to Treatment?(City, State, Zip) Number of Previous Treatment EpisodesHave You Ever Lived in a Recovery Home Before? Yes No If Yes, Please List Location(s)HEALTH INFORMATIONMedical Conditions (If Any)Mental Health Diagnosis (If Any)List of Current MedicationsBACKGROUND INFORMATIONHave You Ever Been Convicted of or Charged as a Sex Offender?(Required) Yes No Have You Ever Been Charged or Convicted of Arson?(Required) Yes No ACTIVITIES OF DAILY LIVING (ADL)Please Indicate if you are Currently Able to Perform the Following Tasks Independently, or if You Require AssistanceBathing/Personal Hygiene(Required) Independent Need Some Assistance Cannot Perform Dressing(Required) Independent Need Some Assistance Cannot Perform Eating/Meal Preparation(Required) Independent Need Some Assistance Cannot Perform Using the Bathroom(Required) Independent Need Some Assistance Cannot Perform Mobility (Walking, Climbing Stairs, Moving Around)(Required) Independent Need Some Assistance Cannot Perform Medication Management(Required) Independent Need Some Assistance Cannot Perform Managing Money/Paying Bills(Required) Independent Need Some Assistance Cannot Perform Transportation (To Appointments, Work, Recovery Meetings)(Required) Independent Need Some Assistance Cannot Perform Staff Notes/Recommendations (This Section to Be Completed Only If a Case Manager/Discharge Planner is Completing This Application on Behalf of Applicant)In Your Professional Opinion, is the Applicant's Level of Functioning Appropriate for Recovery Housing? Yes No Needs Further Evaluation Comments/ObservationsStaff Name & TitleDate MM slash DD slash YYYY DEMOGRAPHICS (For Reporting Purposes Only)This information is confidential and will not affect your eligibility. It helps us understand who we are serving and ensure we are reaching all communities fairly. Gender Identity(Required) Male Female Transgender Non-Binary Other Prefer Not to Say Race/Ethnicity(Required) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Prefer Not to Say Check All That ApplyMarital/Family Status(Required) Single Married Divorced/Separated Widowed Parent with Dependent Children Other Check All That ApplyVeteran Status(Required) Veteran Active Duty Not a Veteran Education Completed(Required) Less Than High School High School Diploma/GED Some College Associates Degree Bachelors Degree Graduate Degree Other Employment Status(Required) Employed Full Time Employed Part Time Unemployed Student Retired Unable to Work Household Income (Optional) Less Than $15,000 $15,000-$29,999 $30,000-$49,999 $50,000-$74,999 $75,000+ Prefer Not to Say PERSONAL STATEMENTPlease Briefly Explain Why You Are Requesting a Recovery Housing Scholarship and How This Support Will Help You in Your Recovery JourneyAttestation(Required) I attest that all information provided in this application is true and correct to the best of my knowledge. I understand that any false or misleading information may result in denial or termination of scholarship assistance. Signature of Applicant(Required)If Completed by a Case Manager, Discharge Planner, Family Member, or Friend, the Applicant's Signature is Still Required for Final Submission.Date(Required) MM slash DD slash YYYY Release of Information(Required) I authorize Hope in the Hills, Inc. (DBA: Healing Appalachia) to contact my treatment provider, case manager, discharge planner, or recovery home for the purpose of verifying the information provided in this application. I understand this information will be used solely to determine my eligibility for a Recovery Housing Scholarship. Signature of Applicant(Required)Date(Required) MM slash DD slash YYYY
