Scholarship Application

Recovery Housing Financial Assistance Scholarship — Temporary financial support for individuals in recovery working toward stability.

Important Disclosure — Please Read Before Proceeding

This form is NOT HIPAA compliant. Bridge to Stability Foundation is a nonprofit financial assistance organization, not a covered healthcare entity under the Health Insurance Portability and Accountability Act (HIPAA). Information submitted on this form is not protected by HIPAA privacy rules.

Completion of this form is entirely voluntary. You are not required to disclose any medical, mental health, or legal information to receive consideration. However, honest responses help us better understand your situation and provide appropriate support. All information submitted is kept confidential within Bridge to Stability Foundation and is used solely for scholarship review purposes.

Personal Information

Full Legal Name *

Email Address *

Phone Number *

Date of Birth

Home / Current Address

Street Address

City

State

ZIP Code

Recovery & Eligibility

Insurance Coverage

Employment Status

Current or Intended Recovery Program

Mental Health & Dual Diagnosis

Voluntary disclosure. This section is not required. Responses help us connect you with appropriate support resources and are not used to determine eligibility in isolation. This information is NOT protected under HIPAA.

Do you have a current or past mental health diagnosis? *

YesNoPrefer not to say

Do you have a dual diagnosis (co-occurring substance use and mental health disorder)? *

Dual diagnosis means being diagnosed with both a substance use disorder and a mental health condition at the same time.

YesNoPrefer not to say

Legal Background

Voluntary disclosure. Legal history does not automatically disqualify an applicant. Non-violent offenses are reviewed on a case-by-case basis. Honest answers allow us to provide the most appropriate support and placement.

Do you currently have any active warrants? *

YesNo

Do you have any pending court cases? *

YesNo

Are you currently registered as a sex offender? *

Note: Being a registered sex offender may impact placement eligibility at certain sober living homes due to housing restrictions. This will be reviewed individually.

YesNo

Personal Statement *

Share your personal history, recovery goals, and how this scholarship will help you achieve stability.

Reference

At least one personal or professional reference (e.g., counselor, social worker, community leader).

Reference Name

Relationship

Phone Number

Acknowledgements & Agreement

Non-HIPAA Voluntary Disclosure Acknowledgement

I understand and acknowledge that Bridge to Stability Foundation is NOT a HIPAA-covered entity. This application form is NOT protected under the Health Insurance Portability and Accountability Act (HIPAA). Any personal, medical, or mental health information I have provided is shared voluntarily. I have not been required to disclose this information as a condition of receiving financial assistance consideration. I understand that information submitted is kept confidential within Bridge to Stability Foundation and will not be shared with third parties without my written consent, except as required by law.

I understand this form is NOT HIPAA compliant and my disclosure is entirely voluntary. *

By submitting this application, I affirm that all information provided is true and accurate. I understand that this scholarship provides temporary financial assistance paid directly to approved sober living homes — no cash is provided to individuals. I agree to actively participate in my recovery, maintain communication with the program, and work toward financial independence. I understand that assistance is time-limited (maximum 12 months per period, one renewal permitted as a lifetime maximum) and that continued support depends on my participation and communication. I consent to periodic check-ins and weekly progress reports from my sober living home manager.

I have read and agree to the participant agreement and scholarship terms. *