Apply for Financial Help

If you need financial assistance for Christian rehabilitation therapy, please complete the online form below or download, print and complete our application form pdf.

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

Christ-centered programs rooted in biblical truth

Minimum 90-day residential care

Clinically trained, Christian staff with a low patient-to-therapist ratio

Comprehensive family counseling, not just individual care

Step 1 of 3

33%

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

Date of Birth (Person Seeking Treatment)(Required)

MM slash DD slash YYYY

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) Do you expect insurance to help with the cost?

Supporting Financial Documents(Required)

Drop files here or

Max. file size: 512 MB.

Please provide supporting documents for why assistance is needed: A) Two most recent federal tax returns - entire return with all schedules (you are welcome to black out social security numbers), B) Retirement and/or investment plan statements, and C) Mortgage statement (if applicable)

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

Yes

Organization Information

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

MM slash DD slash YYYY

Organization Name:(Required)

Address:(Required)

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

Organization's Mission/Purpose:

A brief statement regarding the organization's history:

Description of current programs and activities:

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?

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

For Profit

Non Profit

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.

Net Worth Statement Worksheet

For any field that does not apply, put 0

Cash in Hand(Required)

Cash in Checking(Required)

Cash in Savings(Required)

Money Market Accounts(Required)

Est. Value of Household Items

Money Value of Your Home(Required)

Market Value of Other Real Estate (If Applicable)(Required)

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

Stocks(Required)

Bonds(Required)

Mutual Funds(Required)

Market Value of Vehicles(Required)

Cash Value Life Insurance

Current Value of 401k plan or similar(Required)

Individual Retirement Account(Required)

Estimated Value of Personal Items

Other Assets(Required)

Total Assets

Net Worth Statement Worksheet

For any field that does not apply, put 0

Mortgage Balance(Required)

Home Equity Loan or Line of Credit(Required)

Other Real Estate Loans

Auto Loan or Lease(Required)

Credit Card Balances(Required)

Student Loans

Delinquent Taxes

401(k) Loan(Required)

Personal Unsecured Loans(Required)

Life Insurance Loans

Other Liabilities(Required)

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.

Comments

This field is for validation purposes and should be left unchanged.

If you need to print and fill out our PDF form, you can download a copy by clicking the button below.

PDF Application Form

Our 3-Step Process

Our process is intensive and thorough, focusing on financial need and the support system to ensure we provide the right assistance to those who need it most.

Apply

Applicants complete a detailed application about the individual struggling, their financial situation, and their support network.

Review

We review the application, ask follow-up questions, and conduct a phone interview to determine eligibility based on financial need and a strong support system.

Fund

If approved, we inform applicants, issue grants directly to the facility, and perform periodic progress check-ins.

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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

Our 3-Step Process

Apply

Review

Fund

Apply for Assistance ↘︎

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