Is this application for you or a loved one? * Your Name (First, Last Initial) * YourTelNo2 Your Tel No * Best Time to Call (EST) * Your Email Address MarritalStatus2 Relationship to Client YourEmailAddress2 ABOUT THE CLIENT TravelRestricted2 FrequencyofUse2 Name (First, Last Initial) * Gender * Age * email Date of Birth MonthlyRentMortgagePayment2 Marrital Status * email2 Number of Dependents * YourEmailAddress3 Street Address (Not Required) City * DateofBirth2 State * address Zipcode PriorMedProcedures2 Best Tel * Other Tel 2 Employment Status * 3 If Employed, Is the Employer Sympathetic? ABOUT THE PROBLEM name State2 Please Select All That Apply NameFirstLastInitial2 youremail Frequency of Use * youraddress yourphone Does the Client Require Detox? * Is the Client Currently Taking Medication? * name2 If Yes, Please Specify (Inc Dosage) Zipcode2 HastheClientEverBeenIncarcerated2 Additional Problems If Other, Please Specify PriorMedProcedures3 CLIENT HISTORY Previous Treatment? * MonthlyRentMortgagePayment3 If Yes, Please Specify Year and Location YourEmailAddress4 Medical Conditions HistoryofSelfHarm2 Prior Medical Procedures/ Dates EmploymentStatus2 Has the Client Ever Been Incarcerated? * Isthisapplicationforyouoralovedone2 If Yes, Is Traveling Restricted? ProposedContributionTowardsTreatment2 History of Self Harm? * History of Suicide Attempts? * ABOUT FINANCE 4 Second Chance funding is made up of a treatment loan, client contribution and discounted treatment fees. Clients and/or loved ones are required to pay a contribution towards the cost of treatment, over and above the value of the treatment loan. Proposed Contribution Towards Treatment * Second Chance client treatment loans must be taken out by a sponsor (loved one) on behalf of the client who must meet the following verifiable criteria: (1) Must currently be employed, (2) Must receive a minimum income of $1,500 per month, (3) Monthly rent or mortage payment must not exceed 50% of monthly income, (4) Must be US citizen, (5) Must agree to make all monthly repayments of the Second Chance loan on behalf of the client, (6) Agrees to make payment of the client's contribution towards the cost of treatment prior to the client's admission into treatment, (7) Agrees to pay $250 processing fee on behalf of the client prior to the client's admission into treatment. HistoryofSelfHarm3 Full Name of Sponsor * MonthlyRentMortgagePayment4 Best Tel * Full Street Address * City * AdditionalProblems2 DoestheClientRequireDetox2 State * ZipCode * Employment * Monthly Income * Monthly Rent/ Mortgage Payment * TravelRestricted3 HistoryofSuicideAttempts2 Submission of this form does not constitute an agreement by us to provide funding for treatment to the named client, but will provide our clinical team with sufficient information to conduct a telephone assessment. Our clinical team will attempt to contact you at the 'Best Time' specified in this form. By submitting this form you hereby authorize us, after a telephone assessment has been conducted, to share your information with treatment providers who may wish to contact you to conduct their own assessment.
