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Dana's Hope for Recovery Housing Scholarship Application Form

Please fill out the form below and we will reach out to you shortly after.

Applicant Information:

First name

Last name

Birthday

Month

Day

Year

Address

Recovery Information:

Date of sobriety*

Current Recovery Program:

12-Step Program (e.g., Alcoholics Anonymous, Narcotics Anonymous)

SMART Recovery

Celebrate Recovery

Medication-Assisted Treatment (e.g., Suboxone, Methadone)

Outpatient Treatment Program

Inpatient/Residential Treatment Program

Sober Living/Recovery Housing Program

Faith-Based Recovery Program

Therapeutic Community

Counseling or Therapy-Based Program

Harm Reduction Program

Recovery Dharma

Refuge Recovery

Other

Housing Need:

Have you previously stayed in a recovery house?*

Yes

Why do you need recovery housing? (Please provide a brief explanation of your current situation)*

How will stable recovery housing benefit your recovery journey?*

Employment Status:

Are you currently employed?*

Yes

If yes, where are you employed and what is your job title?

Financial Information:

Do you have any other sources of financial support?*

Yes

If yes or no, please explain in more detail:*

Can you contribute any amount towards your housing?*

Yes

If yes, how much?

Personal Statement:

Please provide a brief statement (300-500 words) about your recovery journey, your goals, and how this scholarship will help you achieve them:*

References:

Reference #1: (Name, Relationship, Phone and Email):*

Reference #2: (Name, Relationship, Phone and Email):*

Outer Beauty, Inner Calm

How Can We Support You?

Office: 708-657-4024

Cell: 773-398-2305

E-mail: dora@thepathrecovery.org

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