Scholarship Application Scholarship Application Name* First Last Phone*Email* Are you over the age of 18?* Yes No How did you hear about Sana Lake?* Are you currently covered under any form of health insurance?* Yes No Have you ever been covered by health insurance?* Yes No When was the last time you were covered by health insurance?* MM slash DD slash YYYY Is there an ability to Cobra?* Yes No I don't know Do you have Medicare or Medicaid?* Yes No Have you attempted to secure finances for treatment from family or friends?* Yes No What 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?* Yes No Describe 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.) Yes No Please 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) Yes No Please 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?* Yes No If 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?* Yes No Applications that are not chosen will be discarded and applicants can reapply in 1 year from when they applied. Does that work for your needs?* Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
