Financial Assistance Form — New Beginnings

PERSONAL INFORMATION

Full Name: (required)

Date of Birth: (required)

Age: (required)

Phone Number: (required)

Email Address: (required)

Marital Status:

Spouse Name:

Spouse Phone:

Are you a veteran or LEO?

Level of care interested in:

Do you have transportation?

Highest level of education?

ADDRESS INFORMATION

Where have you been staying?

How long have you been staying there?

Who owns/rents the residence?

CHILDREN (Under 18 y/o)

How many children do you have?

Age of children?

Who are the current guardians of children?

INSURANCE

Company:

Subscriber Name:

Subscriber relation to you:

Subscriber DOB: (mm/dd/yyyy)

Insurance Phone Number:

Policy #:

Group #:

How are you receiving this insurance?

Are you working:

How long have you been working at current job?

What is your salary/hourly wage?

Are you on welfare?

Are you on food stamps?

ONLY IF UNEMPLOYED:

How long have you been unemployed?

Where was your last job?

Why do you no longer work there?

DRUG/ALCOHOL USE:

How old were you when you began to drink/use?

Is family aware of your substance use?

When did your use become daily/problematic?

Did family members use drugs/drink heavily when you were a child?

What is your Drug(s) of Choice?

How long have you been on a run for?

How much of your substance are you taking?

How often are you taking/using it?

Have you been to any other treatment centers before?

If so, any clean time?

Were you ever kicked out of a treatment center?

Have you ever been involved in a 12 step fellowship?

LEGAL:

Do you have any pending charges, upcoming court dates, or are you on probation?

Any felonies?

Please list if so.

MENTAL HEALTH:

Do you have a history of anxiety, depression, insomnia, bipolar, etc?

If so, please list illnesses and how long you have been suffering with it.

Are you on any current medications for mental health?

Please list if so.

Recent Baker Acts or suicide attempts?

Please list if so.

HEALTH:

Do you have any illnesses, chronic pain, or health issues?

If so, please list health problems and how long you've been suffering with it.

Are you taking any medications for any health problems?

Please list if so.

SAVINGS:

How much do you have in your:

Savings?

Checking?

Retirement?

Investments?

Real Estate?

FAMILY:

Any family members who would be willing to help financially?

GENERAL:

Why do you want to be clean/sober?

What events brought you to deciding you want recovery?

Please describe your situation below and why you need financial aid.

NOTE: All information in this document will be kept totally confidential and will not be shared with any outside agencies or individuals.

Phone:	888-840-5189
Email:	[email protected]
Address:	741 US Highway 1 North Palm Beach, Florida 33408