Scholarship Application Scholarship Application Name* First Last Phone*Email* Are you over the age of 18?*YesNoHow did you hear about Sana Lake?*Are you currently covered under any form of health insurance?*YesNoHave you ever been covered by health insurance?*YesNoWhen was the last time you were covered by health insurance?* Date Format: MM slash DD slash YYYY Is there an ability to Cobra?*YesNoI don't knowDo you have Medicare or Medicaid?*YesNoHave you attempted to secure finances for treatment from family or friends?*YesNoWhat is your current living situation?*For example: in your own home/apt, with parents/family, shelter, etc.What is your current substances(s) of choice?*Have you tried treatment before?*YesNoDescribe the conditions under which you left the previous program(s) and your follow through upon leaving:*Do you have any issues aside from drugs and alcohol that need to be addressed?*(for example: eating disorder, anxiety, etc.)YesNoPlease explain any issues aside from drugs and alcohol you are struggling with, including any treatment history:*Do you have any current or prior medical history we should be aware of?*(example: open wounds, HIV, Hepatitis, breathing issues, liver, kidney or blood disorders)YesNoPlease describe any medical conditions or history that we should be aware of:*In a short paragraph please tell us why you should receive a Sana Lake scholarship:*Do you understand this application is not a guarantee for treatment?*YesNoIf you agree to receive a scholarship for our inpatient residential program, you are also agreeing to follow our full continuum of care for the next 12 months. Do you agree to these terms?*YesNoApplications that are not chosen will be discarded and applicants can reapply in 1 year from when they applied. Does that work for your needs?*YesNoCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
