Request Assistance If you are in need of financial assistance, please fill out the form below to make a request. Assistance RequestApplicant InformationFirst NameLast NameDate of BirthGender Male FemalePhone NumberEmailCurrent AddressStreet AddressCityStateZip CodeHousehold InformationNumber of People in HouseholdEmployment & Financial InformationEmployment Status- Select -Employed Full-TimeEmployed Part-TimeUnemployedDisabledOtherType of Assistance Requested Rent / Housing Support Utilities Food Assistance Transportation Recovery / Treatment Support Emergency Financial Help OtherOther Assistance RequestedDollar Amount RequestedNOTE: Any assistance granted must be able to be paid directly by non profit. No cash/checks will be given to applicants. Situation & NeedImpact StatementDo you currently have a substance use disorder, or are in short or long term recovery? Yes NoAgreement I certify that the information provided is true and accurate to the best of my knowledge. I understand that submission of this application does not guarantee assistance.Submit Request Help us on our mission to provide support and advocacy for individuals and families struggling with substance use disorder Help Us On Our Mission