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Recovery Communication Fund Grant Application
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* Indicates required question
Name:
*
Your answer
Address:
*
Your answer
Applicant Phone Number:
Your answer
County of residence (note this grant is currently only available in Hancock and Washington Counties)
Your answer
Is it ok to leave a message at this number?
Yes
No
Clear selection
If no number is available, please provide the best way to reach you
Your answer
What are you requesting funds for?
Cell Phone Service
Internet Service
Cell Phone
PrePaid Phone Cards
Other:
Clear selection
Person Completing this application
Self
Recovery Coach
Mental Health Provider
Medical Professional
Other:
Clear selection
Are you affected by Substance Use Disorder?
Yes
No
Other:
Clear selection
Are you requesting funds for service, device or both? (This can include internet service) if you are not sure, please answer NA)
Your answer
Do you currently have a Recovery Coach?
*
Yes
No
If 'Yes' what is your coaches name?
Your answer
Would you like more information about Recovery Coaching Services?
Yes
No
Clear selection
If you are granted these funds, how will this connectivity help you in your recovery?
*
Your answer
Additional comments and/or instructions
Your answer
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