Apply for Help

Your Name(Required)

Person completing this application.

First Last

Are you the person seeking treatment?(Required)

Yes

Name of Person Seeking Treatment(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Please provide details describing your entire family, including ages, occupation, education and any other information that might be relevant to this application(Required)

Who in your family is struggling with addiction? Provide a detailed description of the addiction, such as how the individual's situation developed and specifically how the individual's needs align with the mission of Ashes to Glory Foundation.(Required)

Have any steps already been taken to overcome the addiction, including prior therapy programs? If so, please explain and identify any such programs and the dates attended.(Required)

Describe the effects of the journey on the family and on the individual, such as job loss of job, effect on family relationship, etc.(Required)

Does the person struggling with addiction want help? If not, how do you intend to get them to a point of wanting help?(Required)

How much financial assistance do you need? Be specific.(Required)

Provide evidence as to why assistance is needed for that amount, including the following information for the entire family: A) Adjusted gross income for prior three years, B) List of assets and liabilities and C) Two most recent federal tax returns – entire return with all schedules. You are welcome to black out social security numbers.

Do you already have an organization that you would like to use to help with therapy?(Required)

Yes

Organization Information

Organization Name:(Required)

Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code

Organization's Mission/Purpose:(Required)

A brief statement regarding the organization's history:(Required)

What is the breakdown of costs for a patient to receive treatment?(Required)

Does the organization provide minimum 90 day programs?(Required)

Yes

Does the organization provide counseling for the entire family?(Required)

Yes

What is the organization's patient/counselor ratio?(Required)

Is the organization a "for profit" or a "non-profit" entity?(Required)

For Profit

Non Profit

Description of current programs and activities:(Required)

Is the organization willing to enter into a Grant Agreement with Ashes to Glory Foundation to ensure proper use of grant funds?(Required)

Yes

Please provide any brochures or other information about the organization.

Max. file size: 512 MB.

What date do you hope to enter treatment?(Required)

MM slash DD slash YYYY

Net Worth Statement Worksheet

Cash in Hand

Cash in Checking

Cash in Savings

Money Market Accounts

Est. Value of Household Items

Money Value of Your Home

Market Value of Other Real Estate

(i.e. investment or rental property, timeshare, vacation home)

Stocks

Bonds

Mutual Funds

Market Value of Vehicles

Cash Value Life Insurance

Current Value of 401k plan or similar

Individual Retirement Account

Estimated Value of Personal Items

Other Assets

Total Assets

Net Worth Statement Worksheet

Mortgage

Home Equity Loan or Line of Credit

Other Real Estate Loans

Auto Loan or Lease

Credit Card Balances

Student Loans

Delinquent Taxes

401(k) Loan

Personal Unsecured Loans

Life Insurance Loans

Other Liabilities

Total Liabilities

Net Worth

How did you hear about Ashes to Glory Foundation?(Required)

Signature(Required)

By signing below I agree that all of my answers are correct to the best of my knowledge.

Name

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Apply for Financial Help

We help families afford quality treatment centers that meet the following criteria:

Organization Information

Net Worth Statement Worksheet

Net Worth Statement Worksheet

PDF Application Form

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