Soulful Living for Recovery Grant Program | The Holistic Center for Soulful Living

SOULFUL LIVING FOR ADDICTION & LONG TERM RECOVERY is a 501(c)(3) non-profit organization

PLEASE NOTE: Your application WILL NOT BE CONSIDERED FINAL until your proof of income (tax returns, W-2’s and bank records) are submitted to: [email protected].

First name *

Last name *

Full name at birth *

Date of birth *

Address *

City *

State *

Home phone

Cell phone

Email *

How did you hear about our healing services?

What attracted you to our Center's Program?

In one sentence, please describe why you are here?

Do you experience problems with addiction?

Is there a history of addiction in your family?

Are you currently working and what's your work history? (What is fulfilling about your job and/or what was fulfilling about your past jobs?)

What do you do in your free time?

Have you had any past or do you have any present medical issues (surgeries)?

Are you taking any medications? Including any holistic remedies?

Have you tried any traditional or non-holistic therapies? If so which ones and what was your experience?

Do you have any self-care rituals involving eating habits, meditation, yoga and/or exercise? Are there areas in which you would like to improve upon or explore?

What are your normal sleeping hours? Do you sleep well? Do you often wake up at night?

What are some of the major stressors in your life? How do they impact you?

Do you have a circle of support including family, friends, work contacts or any support programs?

What are your treatment goals and expectations for your healing?

Which of the following is the MOST important to you?

Keeping in mind your biggest dream, what would you attempt to do if you knew you could not fail?

Household size

Combined Annual Household Income

Describe your living situation (i.e., live at home with parents, etc.)

Tell us anything else we need to know about your financial situation (i.e. extenuating circumstances that may be contributing to economic hardship).

Proof of income (tax returns, W-2’s and bank records) Up to 15 files can be uploaded. -- Max file size per file is 512MB

Click or drag files to this area to upload. You can upload up to 15 files.

Confirmation all information on this form is correct *

Please sign here (write your name)

Date *

Name

PLEASE NOTE: Your application WILL NOT BE CONSIDERED FINAL until your proof of income (tax returns, W-2’s and bank records) are submitted to: [email protected].